The treatment of child and adolescent depression: a matter of concern?

In their interesting clinical overview Antidepressants in child and adolescent depression: where are the bugs? Moreno et al. describe an important topic which has drawn much attention from clinicians, researchers and the media throughout the last few years (1). Antidepressants are widely used in child and adolescent psychiatry, primarily for depression but not only for this diagnosis (2). Also obsessive–compulsive disorder, anxiety disorders, selective mutisme and bulimia nervosa are often treated with antidepressant drugs. Depression in children has gained much more focus, and acceptance that this condition may actually occur in children as well as in adolescents and adults has been increasing (3). There has, in most of the Western world, been an increasing use of antidepressant drugs in children and adolescents. As acknowledged by the authors, the evidence of efficacy has been limited. Many drugs have shown some efficacy but a high placebo response rate has been reported in most studies. Some studies with negative results have not been published (4) so the evaluation of positive or negative effects of the antidepressants has been biased. Most of the published studies have been sponsored by the industry. In many of the published studies there seems to be an effect on secondary but not primary parameters, meaning that the specific effect on the defined clinical depressive symptoms may often be limited whereas the global improvement seems to be greater. This leads to some interpretation difficulties, i.e. what seems to be the effect of the treatment? Furthermore, most studies seem to exclude patients with considerable comorbidity, such as suicidal risk which may skew the patients, so that studies may only to a limited degree reflect true clinical populations. There seems to be a need for further studies including real patients with usual comorbid symptoms and diagnoses. I fully agree with the Moreno and co-workers speculations of why results regarding the efficacy of antidepressants are less convincing in childhood depression than in adult depression: methodological issues, sample size, heterogeneity of the population studies (in terms of severity, sex, and age), presence of comorbidity which is seen in most referred children with depression – a fact which may complicate treatment and greatly influence the success of the intervention (5). Regular biological differences, i.e. that depression in prepubertal children is of another biological type in terms of symptoms, hormonal changes and causal pathways, may be part of the explanation. Some findings, for instance, show that genetics in smaller children with depression play a lesser role than in adolescent depression (6). Much attention has been on the potential side effects caused by the use of antidepressants. This is a topic which is only slightly touched by the authors. Concerns about increased suicidal risk have been expressed by the American and British Drug Administration, and by the EU. A recent Danish study by Søndergaard et al. included all persons aged 10–17 years treated with antidepressants during a 5-year period and a randomly selected control group (7). The authors analysed the changes in youth suicide and use of antidepressants. They further analysed the relative risk of suicide according to antidepressants corrected for psychiatric hospital contact to minimize the problem of confounding by indication. They found, not surprisingly, that the use of selective serotonin reuptake inhibitors (SSRIs) among children and adolescents increased during the study period but that the suicide rate remained stable. Among 42 suicides in the sample during the period, none was treated with SSRIs within 2 weeks prior to the suicide. The authors found an increased rate of suicide associated with SSRIs, however not significant when adjusted for severity of illness. In conclusion, the authors state that they were not able to identify an association between treatment with SSRIs and completed suicide among children and adolescents. An American study by Valuck et al. (8) used a retrospective, longitudinal cohort using paid insurance claims for analysing the potential empirical link between antidepressant treatment and suicide attempts among adolescents aged 12–18 years. The authors Acta Psychiatr Scand 2007: 115: 169–170 All rights reserved DOI: 10.1111/j.1600-0447.2007.01003.x Copyright 2007 The Authors Journal Compilation 2007 Blackwell Munksgaard