In last month’s column I discussed identifying and assessing depression in children and adolescents using one of several validated screening tools. This month, I’d like to review the GLAD coalition’s actual treatment recommendations.¹ Based on literature review and expert consensus, three interventions are identified: first, psychosocial, second, psychotherapy, and third, antidepressant treatment.

Counselling

Psychosocial intervention, or counselling, was touched on in October’s column. There’s an excellent description of it in the GLAD-PC Tool Kit (downloadable at www.glad-pc.org). Effective counselling requires an empathetic physician who can help develop a plan of action to deal with depressive symptoms. The assumption here is that most mild adolescent depression stems from the challenges facing any teenager. The Tool Kit recommends 4 to 6 half-hour meetings analyzing the problem and “brainstorming” possible solutions, with follow-up to check progress. I’ve used this approach successfully in community practice with several mildly depressed adolescents, usually in just 4 sessions due to time constraints. An example is a teenage boy who became mildly depressed when he broke up with his girlfriend. We focused on how his self-esteem had been wounded, leading to feelings of depression. The GLAD-PC coalition’s first recommendation is: “After initial diagnosis, in cases of mild depression, clinicians should consider a period of active support and monitoring before starting other evidence-based treatment (grade of evidence B; strength of recommendation: very strong.)”²

Cognitive behavioural therapy

CBT has also been shown to be highly effective for kids with moderate to moderately severe depression. It aims to restructure their thought processes so that they begin having more positive thoughts about themselves leading to increased positive feelings, which then flow into activities of daily living. “Essential elements of CBT include increasing pleasurable activities (behavioural activation) reducing negative thoughts (cognitive restructuring), and improving assertiveness and problem-solving skills to reduce feelings of hopelessness.”³ The time commitment required for such therapy is usually beyond a community physician’s availability, requiring hour-long sessions over 8 to 20 weeks. But elements of the model can be used as a scaffold for counselling sessions as described above.

Pharmacotherapy

Finally, there’s the issue of pharmacotherapy, and here several caveats are in order. First, as I learned from a psychiatrist colleague, never prescribe a medication at the first visit for any problem involving mental health, including depression, anxiety or ADHD. Second, medication should be reserved for major depression that’s seriously interfering with the child’s life — for example, if they’re unable to continue at school. I use medication rarely, and only in conjunction with a trained psychotherapist or after consultation with a child and adolescent psychiatrist. Third, as a primary care physician I don’t follow adolescents who are suicidal without a psychiatrist’s active involvement. The GLAD coalition also suggests consultation with a specialist if a primary care clinician identifies severe depression, coexisting substance abuse or psychosis.

Depression is all too prevalent in children and adolescents, and the community physician can play a major role in diagnosis and treatment. This is even truer today given the shortage of child and adolescent psychiatrists. But we need to use treatments that are evidence-based. On that note, I close by highly recommending that physicians download and examine the GLAD-PC Tool Kit.