Medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy, those who are unable to undergo psychotherapy, those with psychosis, and those with chronic or recurrent episodes. Following remission of symptoms, continuation treatment with medication and/or psychotherapy for at least several months may be recommended by the psychiatrist, given the high risk of relapse and recurrence of depression. Discontinuation of medications, as appropriate, should be done gradually over a period of 6 weeks or longer.
Antidepressant medication for children is a controversial topic. Currently no medications have FDA approval for use with children, although most of the major drug companies have submitted data. There are no long-term studies that show what kind of impact this medication will have on a child's development.
If a child's depression has been caused wholly or in part by psychological factors, medication may relieve the depression, but the underlying cause will not be "cured" by medication alone. Therapy can help the child deal with his past in a healthy manner, and to learn ways to cope with the very difficult process of growing up.
Recent research shows that certain types of short-term psychotherapy, particularly cognitive-behavioral therapy (CBT), can help relieve depression in children and adolescents. CBT is based on the premise that people with depression have cognitive distortions in their views of themselves, the world, and the future. CBT, designed to be a time-limited therapy, focuses on changing these distortions. A study supported by the National Institute of Mental Health (NIMH) found that CBT led to remission in nearly 65 percent of cases, a higher rate than either supportive therapy or family therapy. CBT also resulted in a more rapid treatment response.
Psychotherapy is almost always the first treatment of choice, except in cases where depressive symptoms are so severe or critical that immediate relief is necessary to restore functioning and to prevent immediate and severe consequences. Medication is usually the second choice after a comprehensive and competent trial of psychotherapy. Combined use of medications and psychotherapy at the onset of treatment can confound evaluation of treatment effectiveness and the observed source of change. It is harder in a combined medication and therapy approach to tell which approach is or is not helping and how much it is helping. However, research has found that combined psychotherapy and medication is often necessary and beneficial. Psychotherapy can be a very effective alternative to the use of medications.
Psychotherapy requires significant commitment whereas treatment of depressive disorders with medication requires less effort. Since normal depression can improve over time and without therapy, a brief period of medication may not be of benefit. Psychotherapy can be helpful in cases of normal depression and can help insure the condition does not become chronic. Psychotherapy can generally be considered ineffective if a trial of three months has not produced a measurable and noticeable improvement. A decision to change therapists or to start a medication may be necessary at this point. Antidepressant medications require a substantial period of time before they take effect and several trials of different medications may be necessary to find a medication that actually works. Medications alone appear to be helpful in approximately 50% of the cases. However, the use of medications require a substantial commitment for a period of time up to nine months. In some cases, a patient can terminate their medications after six to nine months without a risk of relapse. Unfortunately, there is no way to know if a person will relapse. Several trials of psychotherapy or medications may be necessary to successfully treat depressive disorders.
The prognosis for treatment of depression in children is good. Positive treatment outcomes are primarily dependent on a correct diagnosis, an understanding of the etiology, and implementing an appropriate intervention.
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