A large NIH-sponsored multisite trial found fluoxetine(Drug information on fluoxetine) plus CBT superior to fluoxetine alone, CBT alone or placebo (March et al., 2004). Neither fluoxetine monotherapy nor CBT demonstrated greater efficacy than placebo on primary outcome measures. At this time, fluoxetine is the only agent approved by the FDA to treat depression in juveniles.
The Psychopharmacologic Drugs and Pediatrics Advisory Committees reviewed 24 trials (n=4,400), and found a 4% risk of suicidality during the first few months of antidepressant treatment, compared to a 2% risk with placebo (FDA, 2004). A black box warning was issued, with recommendations for informed consent and frequency of monitoring. Yet, there are also concerns over not treating depressed youth, since pharmaco-epidemiological data suggest that the use of SSRIs may be associated with an overall decreased risk in suicide (Brent, 2004). Ongoing research is needed to address these concerns.
Finally, although mood stabilizers and atypical antipsychotics are widely used in treating young patients, the number of controlled trials examining their use in this population is inadequate (Pappadopulos et al., 2004). In clinical settings, aggression is probably the most commonly targeted symptom. The number of children and adolescents being diagnosed with bipolar disorder, an area of debate within child psychiatry (see McClellan, 2005), has helped drive this practice, with a significant rate of polypharmacy (Duffy et al., 2005).
Although psychotherapy remains a mainstay of psychiatric treatment, current evidence suggests that the most widely used traditional therapies are not effective in youth (Weiss et al., 2000, 1999; Weisz and Jensen, 2001). Research-based psychotherapeutic interventions have documented effectiveness, yet are generally not used in clinical practice.
The best-supported psychotherapy interventions in youth are CBT, parent training and psycho-educational strategies. Cognitive-behavioral therapy has been found helpful for depression, anxiety, posttraumatic stress disorder and conduct problems (Cohen, 2003; Compton et al., 2004; Kazdin, 2000). Interpersonal psychotherapy has also been shown to be beneficial for adolescent depression (Mufson et al., 2004). Parent training programs have been developed to improve parent-child interactions, enhance parenting effectiveness and reduce coercive interactions (Brestan and Eyberg, 1998).
For more seriously impaired youth, including those with conduct problems and substance abuse, multisystemic therapy (MST) utilizes aggressive case management, comprehensive psychiatric services and targeted family interventions to maintain youth in their home communities (Henggeler et al., 2003, 2002). A meta-analysis of MST outcome studies noted positive benefits, although maintenance of treatment fidelity when transporting the intervention to different community settings remains a challenge (Curtis et al., 2004; Henggeler, 2004).