Management
The aims of management are:
1.
to make an adequate assessment;
2.
to treat the depressive disorder, and reduce
associated psychosocial impairment;
3.
to manage associated comorbidity and risk
factors;
4.
to prevent relapse.
Initial assessment:
This largely depends on the
context in which the young person is seen and the
expected level of severity of the problems. Thus,
in primary care settings where youngsters with
milder depression are seen, the brief assessment
will focus on mood, including self-harm risk,
and current difficulties including social function.
Those seen in specialist child and adolescent
mental health services are likely to have more
severe depression with more comorbidity and
complex family situations. In this context a more
detailed assessment will cover developmental
history and functioning at school, as well as family
relationships and other problems.
Treatment:
Treatment of brief or minor depres-
sion will include exploration of difficulties, activity
scheduling, and follow-up. Mild to moderate
depression, where social function might be
impaired, should be managed initially with psy-
chological treatment [16]. Most frequently used
is cognitive–behavioural therapy (CBT), which
starts with psycho-education and includes self-
monitoring, for example, diary keeping, increasing
competence in emotion recognition, challenging
cognitive distortions, and activity scheduling. An
alternative appropriate psychological therapy
is interpersonal psychotherapy for adolescents
(IPT-A), which addresses problem relationship
areas such as role conflict, transitions or losses.
While both CBT and IPT-A have evidence for
effectiveness [16] there are currently few child
mental health professionals in the UK trained in
IPT-A, but CBT is becoming widely available.
More persistent moderate or severe depression
will require antidepressant medication. Recent
studies, predominantly with adolescents, sug-
gest that selective serotonin reuptake inhibitors
(SSRIs), particularly fluoxetine, are helpful [17]. In
recent years there has been a high level of concern
regarding the possible increase of suicidal events
with the use of SSRIs. Although the increased
risk is slight, close monitoring is appropriate.
Failure to respond to fluoxetine can be managed
with a change to another SSRI, or another class
of antidepressant such as venlafaxine, with the
addition of CBT [18]. Poor progress or high risk
of self-harm may require psychiatric admission.
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