ANTI DEPRESAN

Treatment
Treatment includes developing a comprehensive plan to treat the depressive episode and help
the family to respond more effectively to the patient's emotional needs. Referrals should
always be made for individual and family therapy. Cognitive behavioral therapy (CBT) has
been shown to effectively improve depressive symptoms in children and adolescents. CBT
includes a focus on building coping skills to change negative thought patterns that
predominate in depressive conditions. CBT also helps the young person to identify, label, and
verbalize feelings and misperceptions. In therapy, efforts are also made to resolve conflicts
between family members and improve communication skills within the family.
When the symptoms of depression are moderate to severe and persistent and have begun to
interfere with relationships and school performance, antidepressant medications may be
indicated (Table 67). Mild depressive symptoms often do not require antidepressant
medications and may improve with psychotherapy alone. A positive family history of
depression increases the risk of early-onset depression in children and adolescents and the
chances of a positive response to antidepressant medication.
Table 67. Interventions for the Treatment of Depression.

Adjustment disorder Refer for
psychotherapy
Medications usually not needed
Mild depression Refer for
psychotherapy
Medications may not be needed
Moderate
depression
Refer for
psychotherapy
Consider antidepressant medication
Severe depression Refer for
psychotherapy
Strongly encourage antidepressant
medication
Controversy continues regarding the efficacy and safety of antidepressants in children and
adolescents. (See Psychopharmacology section.) Medication for depression should be
monitored carefully, especially in the first 4 weeks and subsequent 3 months, watching
carefully for any increase in suicidal ideation or self-injurious urges.
The SSRIs are usually given once a day, in the morning with breakfast. One in ten individuals may
experience sedation and prefer to take the medication at bedtime. The alternative antidepressants
and fluvoxamine are usually given in twice-daily dosing. Paroxetine, bupropion, and venlafaxine are
now available in a sustained- and extended-release form. Therapeutic response should be expected
46 weeks after a therapeutic dose has been reached. The starting dose for a child younger than 12
years old is generally half the starting dose for an adolescent.
Table 615. Medications Used to Treat Depression in Adolescents.

Generic Trade
Name
Adolescent
Starting Dose
Target Dose (Average
Effective Dose)
Maximum
Dose
Selective serotonin reuptake inhibitors
Citalopram Celexa 20 mg q AM 20 mg q AM 4060 mg q
AM
Escitalopram Lexapro 10 mg 10 mg 30 mg
Fluoxetine Prozac 10 mg q AM 20 mg q AM 60 mg q AM
Fluvoxamine Luvox 50 mg qhs 100150 mg qd 100 mg bid
Paroxetine Paxil 10 mg q AM 20 mg q AM 60 mg q AM
Paroxetine CR Paxil CR 25 mg 25 mg 50 mg
Sertraline Zoloft 25 mg q AM 50 mg q AM 150 mg q AM
Alternative antidepressants
Bupropion Wellbutrin 75 mg q AM 150 mg bid 200 mg bid
Bupropion SR Wellbutrin
SR
100 mg q AM 100 mg bid 150 mg bid
Mirtazapine Remeron 7.5 mg qhs 15 mg qhs 30 mg qhs
Venlafaxine Effexor 37.5 mg q AM 75 mg bid 150 mg bid
Venlafaxine
XR
Effexor XR 37.5 mg q AM 150 mg qd 225 mg qd


q AM, every morning; qhs, every night at bedtime; qd, every day; bid, twice a day.

Antimania
Most patients with bipolar disorder respond to pharmacotherapy with mood stabilizers such
as lithium, carbamazepine, or valproate, either alone or in combination. The atypical
neuroleptics are increasingly being used as primary mood stabilizers to treat bipolar disorder
as primary agents, and olanzapine and risperidone have been approved by the Food and Drug
Administration (FDA) for the treatment of bipolar affective disorder. Quetiapine and
aripiprazole are also being studied as primary medications for this illness. If the individual is
being treated primarily for manic episodes with a non-neuroleptic mood stabilizer (such as
lithium) the addition of a neuroleptic medication may be necessary if psychotic symptoms
(hallucinations, paranoia, or delusions) or significant aggression is also present. In cases of
severe impairment, hospitalization is required to maintain safety and initiate treatment.
Although it is often possible to discontinue the neuroleptic medication after remission of
psychotic symptoms, it is usually necessary to continue the mood stabilizer for at least a year,
and longer if the individual has had recurrent episodes. It is not uncommon for the patient to
need lifelong medication. Supportive psychotherapy for the patient and family and education
about the recurrent nature of the illness are critical. Family therapy should also include
improving skills for conflict management and appropriate expression of emotion.
In its adult form, bipolar disorder is an illness with a remitting course of alternating
depressive and manic episodes. The time span between episodes can be years or months
depending on the severity of illness and ability to comply with medication interventions. In
childhood, the symptoms may be more pervasive and not fall into the intermittent episodic
pattern until after puberty.
For children the starting dose is usually 150 mg once or twice a day, with titration in 150- to
300 mg increments. (Dose may vary with the brand of lithium used; consult a
psychopharmacology textbook for medication-specific information.) Oral doses of lithium
should be titrated to maintain therapeutic blood levels of 0.81.2 mEq/L. The drug is
generally given in two doses. Blood samples should be drawn 12 hours after the last dose.

Antipsikosis
The treatment of childhood and adolescent schizophrenia focuses on four main areas: (1)
decreasing active psychotic symptoms, (2) supporting development of social and cognitive
skills, (3) reducing the risk of relapse of psychotic symptoms, and (4) providing support and
education to parents and family members. Antipsychotic medications (neuroleptics) are the
primary psychopharmacological intervention. In addition, a supportive, reality-oriented focus
in relationships can help to reduce hallucinations, delusions, and frightening thoughts. A
special school or day treatment environment may be necessary depending on the child's or
adolescent's ability to tolerate the school day and classroom activities. Support for the family
emphasizes the importance of clear, focused communication and an emotionally calm climate
in preventing recurrences of overtly psychotic symptoms.
Antiansietas
Once the comorbid diagnoses and situations related to school avoidance/refusal have been
identified and interventions begun (ie, educational assessment if learning disabilities are
suspected, medication if necessary for depression or anxiety, or addressing problems in the
home), the goal of treatment is to help the child confront anxiety and overcome it by
returning to school. This requires a strong alliance between the parents and the health care
provider. The parent must understand that no underlying medical disorder exists, that the
child's symptoms are a manifestation of anxiety, and that the basic problem is anxiety that
must be faced to be overcome. Parents must be reminded that being good parents in this case
means helping a child cope with a distressing experience. Children must be reassured that
their symptoms are caused by worry and that they will be overcome on return to school.
A plan for returning the child to school is then developed with parents and school personnel.
Firm insistence on full compliance with this plan is essential. The child is brought to school
by someone not likely to give in, such as the father or an older sibling. If symptoms develop
at school, the child should be checked by the school nurse and then returned to class after a
brief rest. The parents must be reassured that school staff will handle the situation at school
and that school personnel can reach the primary health care provider if any questions arise.
If these interventions are ineffective, increased involvement of a therapist and consideration
of a day treatment program may be necessary. For children with persistent symptoms of
separation that do not improve with behavioral interventions, medications such as SSRIs
should be considered. Comorbid diagnoses of panic disorder, generalized anxiety disorder, or
major depression should be carefully screened for, and if identified, treated appropriately.