The most effective treatment for depression (and suicidal ideation) is early and rapid treatment. People who are depressed are particularly likely to kill themselves, or make a serious attempt, early in the course of their illness. (Jamison, p. 114). “Recent studies . . . have indicated that treatment of children with depressive symptoms who do not yet meet the criteria for depression may prevent episodes of depression.” (Goldman & Beardslee, “Suicide in Children and Adolescents,” Chapter 24, p. 441, Harvard Guide).
A therapist should be able to offer a clear diagnostic picture and “with your input [the parents] and support, he will then develop and outline a specific treatment plan.” (Fassler & Dumas, p. 130). Parents can be a poor judge of when a child is depressed, frequently thinking that the symptoms are merely a stage of normal development. (Cytryn & McKnew, p. 145). Also, children who feel sad or hopeless often do not reveal these feelings to parents. But if a child is irritable when sad, a parent may identify that symptom. (Id. at 149). However, alert parents can play “a vital role” by identifying symptoms of depression, especially when they “interfere with the child’s ability to play with friends or take part in daily activities or in school.” (Fassler, David G., M.D., “Childhood Depression: Early Recognition Leads to Successful Treatment,”. DSM-IV states that “information from additional informants [besides the patient] can be especially helpful in clarifying the course of current or prior Major Depressive Episodes . . . (DSM-IV, p. 324).
Medications, especially the newer selective serotonin uptake inhibitors (SSRIs, which include Prozac and Zoloft), are a highly controversial means of treating children and adolescents for depression. Statistically, they have been shown to be effective in relieving depression symptoms in children and adolescents, as well as in adults. (NIMH; Ingersoll & Goldstein, pp. 104-05; Mourilehe P & Stokes, P.E., “Risks and Benefits of Selective Serotonin Reuptake Inhibitors in the Treatment of Depression,” Drug Safety, Jan. 1998, abstract from National Medical Library on-line). Since they began being prescribed to children a decade ago, the suicide rate among that age group has declined. Among the benefits of medication for depression are improved ability to cope, improved concentration, improved sleep and energy and decreased irritability and anxiety. (Ingersoll & Goldstein, p. 111). Significant benefits are especially likely when the child has a family history of depression, which has been successfully assisted by medication. (Fassler & Dumas, pp. 140-41). However, it cannot be overemphasized that only a highly qualified medical doctor specializing in mental illness (i.e., a psychiatrist), and, preferably, one specializing in child psychiatry, should be trusted with prescribing antidepressants for children. There are many risks, including a recently-recognized possibility of greater suicidal thinking in 3 percent of patients, and the misuse of antidepressants on bipolar children, which can also cause suicidal thinking and death. A panel of the Federal Food and Drug Administration has recommended strong warning labels against use of antidepressants in children but, recognizing the conflicting data and many stories of children helped by such drugs, has not recommended their use be banned with children.
The evidence is strong that serotonin, which most modern antidepressants increase, inhibits violent, aggressive, and impulsive behavior, but what do we know about the connection between these behaviors and suicide? Several lines of observation converge to support a compelling association. First, we know that suicidal acts are often impulsive; that is, they are undertaken without much forethought or regard for consequences. More than half of suicide attempts occur within the context of a premeditation period of less than five minutes, and many researchers and clinicians, as well as patients, who survive medically serious suicide attempts, lay stress on the role of impulse in the decision to commit suicide. Jamison, p. 189. See also p. 245.
Although many antidepressants take several weeks to become fully effective, they begin to alter brain chemistry with the first dose. (NIMH). “Most children who respond to lithium get clearly better in four to seven days.” (Cytryn & McKnew, p. 142). SSRIs affect clinical action in the first two weeks of treatment. (Katz, M.M., Koslow, S.H. and Frazer, A., “Onset of Antidepressant Activity: Reexamining the Structure of Depression and Multiple Actions of Drugs,” Depression/Anxiety, 1996-97, pp. 257-67, Archives of General Psychiatry). Fluoxetine (Prozac) may provide more rapid onset of therapeutic effect because it can be started at close to its full therapeutic dose. (Mourilhe & Stokes). All of the SSRIs also are effective at reducing the frequency of attacks of anger in depressed patients. (Fava, M. & Rosenbaum, J.F., “Anger Attacks in Patients with Depression,” Journal of Clinical Psychiatry, 1999; 60 Suppl. 15:21-4, abstract). However, drug company studies on which some (but not all) of these observations are based have recently come under attack as failing to disclose the dangers of the drugs.
(Recent news events in the area of medications are summarized on the News Items section of this web site. The Depressed Child also offers a commentary on the phony issue of drugs v. counseling which will provoke some thought on the subject).
Although the preferred treatment for severe depression is both medication and psychotherapy (Cytryn & McKnew, p. 143), psychotherapy alone is unlikely to prevent suicidal individuals from killing themselves. “The ability to diagnose psychopathology accurately and to refer patients to colleagues for medication when necessary is a nonnegotiable fundamental of good clinical practice. Not to do this is malpractice.” (Jamison, p. 253). Fortunately, most children are not suicidal, though it is difficult to identify those who are. Drug therapy might not be appropriate for all or even most depressed children. But a wise parent will consult both a psychiatrist and a psychologist for treatment to try to be sure. It is, however, expensive, not fully covered by insurance, and in many areas of the country child psychiatrists are unavailable. If necessary, rely on a psychiatrist who has had children as patients. Most communities have child psychologists.
DISCLAIMER: Unless otherwise indicated, all commentary and information on this web site is provided by persons who have no formal training in medicine or mental health. You should weigh the information and comment on this site in consultation with a mental health professional.