DEPRESSION IN ADULTS, CHILDREN AND ADOLESCENTS

Much of this guideline is based on existing guidelines for clinical practice developed by
the Agency for Health Care Policy and Research (AHCPR) Depression Guideline Panel
(Rush et al., 1993a; 1993b); The American Psychiatric Association Depression Guideline
Panel (APA, 1993); and the American Academy of Child and Adolescent Psychiatrys
(AACAP) Practice Parameters for the Assessment and Treatment of Children and
Adolescents with Depressive Disorders (AACAP, 1998).
1. INTRODUCTION EMOTIONAL AND PHYSIOLOGIC
MANIFESTATIONS OF DEPRESSIVE DISORDERS
Depression is a symptom of several disorders that range from mild to severe, and from
transitory to chronic. The onset of depression can occur at any age and may be triggered
by a single event or a series of events. These events may be experienced as traumatic or
insignificant at the time and usually require careful clinical assessment to be fully
understood. Anyone who has been the victim of a crime is likely to experience the event
as upsetting or traumatic and, therefore, may experience some depressive symptoms.
Depressed mood alone does not constitute a depressive disorder. Depression as a mood
disorder in adults can include a variety of emotional and physiological symptoms. These
are summarized below and the DSM-IV (1994) diagnostic criteria for depression are
presented in Table 1.
In the emotional arena, symptoms can be expressed verbally or non-verbally, and can
include: sadness, tearfulness, low self-esteem, obsessive self-critical thoughts, inability to
experience pleasure, loss of ambition, loss of interest, indecisiveness, inability to
concentrate, irritability, anxiety, anger, pessimism, guilt, helplessness, hopelessness, and
suicidal fantasies. Any one or more of the emotional states listed above may be the
primary emotional state of a person suffering from depression, not just sadness.
In the physiologic arena, symptoms can include: fatigue, insomnia, increased need
for sleep, increase or decrease in appetite, anorexia, digestive problems,
constipation, social withdrawal, sexual dysfunction, and hypochondriasis.
For children and adolescents, the clinical manifestation of depression varies across
developmental stages and diverse ethnic groups, but is generally analogous to adult
symptoms (see Table 1). When compared to adults, children and adolescents generally
present with more symptoms of anxiety (i.e. phobias and separation anxiety), somatic
complaints, auditory hallucinations and increased irritability. Instead of verbalizing
feelings, children may express increased irritability and frustration through temper
tantrums and behavioral difficulties. Children have fewer delusions and fewer serious
suicide attempts than adults; this is attributed to the lack of cognitive maturation in
children. In middle to late childhood, children report more cognitive components of their
depressed mood, as well as low self-esteem, guilt, and hopelessness. Adolescents tend to
experience more sleep and appetite disturbances, delusions, suicidal ideation and

attempts, and impairment of functioning than younger children, and more externalizing
behavioral problems than adults.
TABLE 1: DEPRESSIVE DISORDERS DSM-IV DIAGNOSTIC CRITERIA
Major Depressive Disorder (MDD), Single Episode Criteria 296.2x
A.

Presence of a single Major Depressive Episode:

(1)

At least 5 of the following symptoms must be present every day or nearly every
day during the same 2-week period and represent a change from previous
functioning.
At least one of the following symptoms is either:
* Depressed mood, or
* Loss of interest or pleasure.

(2)

Symptoms: 5
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)

Depressed mood most of the day, as indicated by either subjective account or

observation by others. In children and adolescents mood can be irritable.
Markedly diminished interest or pleasure in all, or almost all, activities.
Significant weight loss when not dieting or weight gain, or decrease or increase in
appetite. In children consider failure to make expected weight gains.
Insomnia or hypersomnia.
Psychomotor agitation or retardation (observable by others).
Loss of energy or fatigue.
Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional).
Diminished ability to think or concentrate, or indecisiveness.
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
w/o a specific plan, or a suicide attempt or a specific plan for a suicide attempt.

B.

The Major Depressive Episodes are not better accounted for by Schizoaffective
DO and are not superimposed on Schizophrenia, Schizophreniform DO,
Delusional DO, or Psychotic DO NOS.

C.

There has never been a Manic Episode, a Mixed Episode, or a Hypomanic

Episode.

Key: DO = Disorder, NOS = Not Otherwise Specified.

TYPES OF DEPRESSIVE DISORDERS

Depression may signal both a single primary disorder or a combination of disorders (e.g.,
dysthymia and major depressive episode). The conditions which may underlie depression
must be carefully evaluated to determine what the depression means in a given person.
Since there is no comprehensive guide to the types of depression most prevalent in crime
victims, all possible diagnostic meanings of the depression must be considered. A crime
is a stressful event that can trigger a depressive disorder. Other factors that may increase
the likelihood of a depressive disorder as the result of a crime include: family history of
depressive disorder(s), individual history of depressive disorder(s), suicidal thoughts or
attempts, lack of a social support network, and current or past drug abuse. Women are
twice as vulnerable to depression as men are.
The major categories of depressive disorders, briefly defined below, include:
1)
2)
3)
4)
5)

Adjustment disorder with Depressed Mood (or Mixed Anxiety and

Depression)
Dysthymic Disorder
Bipolar Disorder
Cyclothymic Disorder
Major Depressive Disorder (MDD)

Depressive disorders can also be described differently in diverse cultures, such as

nerves or headaches in Latino cultures, imbalance in Asian cultures, and
heartbroken in some Native American cultures.
1.

Adjustment Disorder with Depressed Mood (or Mixed Anxiety and

Depression):

Depressive symptoms or depressive symptoms mixed with anxiety that develop within 3
months in response to an identifiable stressor or stressors. Prevalence of this disorder, as
the primary diagnosis, is approximately 5%-20% in men and women (DSM-IV, 1994).
This condition is by definition acute and generally treatable within six months of onset.
Continuing stressors may lengthen the persistence of the Adjustment Disorder.
Depressive symptoms in Adjustment Disorder are higher than the precipitating event
would logically engender and there is impairment in social or work functioning to some
degree. Treatment generally consists of psychotherapy with occasional short-term use of
psychotropic medication. The diagnosis of Adjustment Disorder does not apply when the
symptoms represent bereavement. Children with this disorder tend to experience mood
fluctuations and impairment of functioning within the three months following the
identifiable stressor; however, they do NOT meet diagnostic criteria for MDD. Overall,
this disorder is associated with less severe mood disturbance, fewer symptoms and no
relapse.

2. Dysthymic Disorder (DD):

Chronically depressed mood that is present most of the time for at least two years for
adults and one year in children. This disorder affects approximately 6% of the population,
more specifically 4% of women and 2% of men (APA, 1994; Rush et al., 1993a).
Depressed mood is not substantially affected by outside stressors. Eating and sleeping
disturbances are common. Identity is linked to depressed mood, and depressed feeling is
experienced as normal. Course of treatment varies, depending on presence of acute
episodes of major depression and degree to which productivity and functioning are
impaired. Dysthymic Disorder often occurs in combination with Major Depressive
Disorder or Personality Disorder. Children with DD may manifest irritable mood instead
of depression. Other symptoms such as feelings of being unloved, anger, selfdeprecation, somatic complaints, anxiety and disobedience have been noted in children.
Fewer children than adolescents suffer from this disorder.
3. Bipolar Disorder:
This disorder is marked by one or more episodes of manic mood which may include:
elation; grandiosity; illogical and/or psychotic thought processes; pressured speech;
decreased need for sleep; increased sociability; distractibility; flight of ideas; impairment
in functioning (especially in structured situations like work); lowered frustration
tolerance; promiscuity; assaultive and/or criminal behavior; and significant deficits in
judgment. Behavior is impacted more seriously than in hypomanic moods which have
many of the same symptoms. These episodic moods may alternate with mild to severe
depressed moods. The classic type of Bipolar Disorder is a mixture of mania and Major
Depressive episodes. Lifetime prevalence of this disorder is 0.4% - 1.6% for both men
and women. Bipolar Disorder usually begins before age 30. Not all types of Bipolar
Disorder include psychotic process. Manic episodes can vary in duration and interval
between episodes but generally occur one to four times a year and without treatment lasts
less than a week. Course of treatment for acute manic episodes is generally less than
three months and includes medication, and when appropriate, psychotherapy.
The nature and course of Bipolar Disorder in children is not yet fully understood and is
currently the subject of some controversy. The primary issues concern whether rapid or
ultra rapid mood cycling and significant difficulties in affective dysregulation constitute
the same disorder that is seen in adults, or leads to Bipolar Disorder as manifested by
adults. It is also especially important that developmentally normal variations in mood
fluctuations and impulsivity not be characterized as evidence of the disorder.
4. Cyclothymic Disorder:
This disorder is a mild form of Bipolar Disorder and includes hypomanic, as opposed to
manic, episodes; depressed mood, as opposed to major depressive episodes; and does not
include psychotic process. Cyclothymic Disorder may become a Bipolar Disorder. A
two-year period of less extreme fluctuating moods without clear internal or external

triggers is necessary to make this diagnosis. Prevalence of this disorder is 0.4% for men
and women. Treatment may include psychotherapy and psychotropic medication.
5. Major Depressive Disorder (MDD):
This disorder is characterized by the following: severe ongoing depressed mood; loss of
pleasure in activities; changes in appetite and sleep; decreased energy; lowered selfesteem; self-critical thoughts; inability to feel happy, sad or to have feelings in general;
feelings of guilt; irritability; psychotic thoughts; indecisiveness; sexual dysfunction;
feelings of sadness or despair; thoughts of death; suicidal thoughts; and impaired
functioning in relationships or at work. A Major Depressive Episode cannot be diagnosed
during the first two months after the death of a loved one. The symptoms of MDD can
vary significantly but must include loss of pleasure and, usually, decreased appetite and
insomnia. This disorder affects 10-25% of all women and 5-9% of all men during the life
cycle. Treatment of an acute episode of MDD includes medication, psychotherapy and,
at times, help with daily life tasks.
MDD affects approximately 2% of children and 4-8% of adolescents. The male-female
ratio is 1:1 in early childhood but 1:2 by adolescence (Birmaher et al., 1996a). It is not
clear why girls are twice as likely to suffer from depressive disorders as boys in
adolescence, but it has been hypothesized that girls carry more risk factors for depression
than boys. For example, girls tend to use more ruminative and self-focused problem
solving styles than boys, worry more about their body image and deal earlier with the
psychosocial and biological consequences that accompany puberty.
CO-MORBIDITY IN ADULTS
Although there is no epidemiological study of depression in the wide spectrum of crime
victims, some well-established findings gathered from trauma survivors with PostTraumatic Stress Disorder (PTSD) would presumably apply, for example, survivors of
war, massive traumas, and natural disaster. Studies have consistently shown that
depression, along with generalized anxiety, is one of the most common co-occurring
diagnoses with PTSD; in fact, almost half of adults suffering from PTSD also suffer from
depression (Kessler et al., 1995). Co-morbidity with PTSD would be expected for
depression due to the overlap in symptom criteria; for example, DSM-IV criteria C and D
PTSD symptoms (e.g. diminished interest, restricted range of affect, sleep disturbances,
difficulty concentrating) overlap with several of the hallmark symptoms of depression.
Substance abuse, as well as eating disorders and obsessive-compulsive disorders, are not
uncommon among individuals suffering from depression. Separate studies of spousal
death or individuals who have experienced physical or sexual assault suggest a significant
number (30%) will meet criteria for depression during the first year of recovery (Jones,
1993). If these depressions begin immediately after the death or assault they are at a
greater risk of persisting and creating dysfunction.

CO-MORBIDITY IN CHILDREN
The majority of children with depressive disorders suffer from other psychiatric
disorders; in fact, 40-90% of youth with MDD have other psychiatric disorders with 2050% having two or more co-morbid diagnoses (AACAP, 1998; Birmaher et al., 1996a).
Studies with traumatized children (e.g., sexually abused, natural disaster survivors) have
revealed that depression often accompanies PTSD symptoms. For example, in a recent
study, McLeer et al. (1998) found that of 80 sexually abused children, 36.3% were
diagnosed with PTSD, and of that group, 13.8% were diagnosed with co-morbid major
depression and 10.3% with dysthymia. The other most frequent co-morbid diagnoses
include anxiety disorders, disruptive disorders, and substance use disorders. Younger
children more commonly manifest Separation Anxiety Disorder, while co-morbid
substance abuse, conduct disorder, social phobia, and general anxiety disorder are more
common in adolescents. Substance abuse and conduct disturbances tend to appear after
the onset of child MDD and may persist after depression remits. Studies have revealed
that depressed melancholic symptoms, fewer recurrences of depression, yet a higher
incidence of adult criminality, more suicide attempts, higher levels of family criticism
and response to placebo.
Overall, co-morbid disorders in depressed children raise concern because they appear to
influence risk for recurrent depression, duration of the depressive episode, suicide
attempts or behaviors, and responses to treatment and mental health service utilization.
There is also particular concern for children suffering from double depressions (MDD
and DD) and co-morbid anxiety and depression; these children often present with more
severe, longer lasting depressive symptomatology, increased risk for substance abuse,
increased suicidality, poor response to treatment, and more psychosocial problems.
CONCEPTUAL MODELS OF DEPRESSION: DYNAMIC VS. ADYNAMIC
While depression is an ubiquitous clinical problem, there is no objective way to diagnose
it beyond the self-report of sometimes non-specific signs and symptoms. With the
introduction of the DSM classification of psychiatric disorders in the 1980s, an
adynamic system, which defines depression as an aggregation of clinical signs and
symptoms, was adopted. By themselves, these signs and symptoms are non-specific, but
their combination over a long enough period of time suggests a threshold or criteria for
the diagnosis of depressive disorders (see Table 1 and the section on diagnosis). There is
a longer standing dynamic concept of depressionthat depressive signs and symptoms
comprise a maladaptive response to a significant loss or to a fixed image of self as
inadequate, helpless and blameworthy. It is appropriate to begin with a presumption that
anyone who has experienced a serious criminal assault, rape or the homicide of a family
member is presenting with a dynamic traumatic event. Signs or symptoms of depression
should be viewed in the context of the occurrence of a traumatic event. Sadness,
hopelessness, insomnia, self-deprecatory ideation, etc. will thus bear some connection to
the persistent memory of the crime. This should not exclude the possibility that
depression as an adynamic disorder may also intervene. These two conceptual models of
depression need not be mutually exclusive. This document will present guidelines for

assessment and management of depression that will include both conceptual models that
will combine psychologic and psychopharmacologic therapies.
2.

ASSESSMENT AND MANAGEMENT OF DEPRESSIVE DISORDERS IN

ADULTS

Detection, Diagnosis, and Assessment

The recognition and diagnosis of depression depends upon a clinicians awareness of risk
factors for depression, as well as presence of key signs, symptoms and history of illness.
Because effective treatments rests on accurate diagnosis, a systematic approach to the
identification of depressive disorders is recommended. Self-report questionnaires can be
extremely useful in screening individuals with significant depressive symptoms that
should be further explored and evaluated through clinical interview. The clinical
interview has been found to be the most effective method for detecting depression
because it allows the clinician to assess the criterion symptoms for depressive disorders
and determine whether the symptoms are of sufficient intensity, number, and duration to
meet the DSM-IV criteria. Once a clinician suspects or diagnoses a depressive disorder, it
is recommended to conduct and record the results of a mental health status examination
assessing suicidal risk and other domains of social, psychological and physical
functioning. However, before conducting extensive biological, neuropsychological, or
psychological testing, a clinician should spend considerable time carefully interviewing
the client and, when appropriate, other informants/caretakers. In other words, the use of
psychological and neuropsychological tests are not recommended for routine use in
screening for depressive disorders. In certain cases, however, these tests may be
extremely useful in differential diagnosis of depression.
6. Diagnostic Instruments
There are a variety of easy to administer, cost effective client self-report measures and
clinician-completed scales readily available to practitioners. Meichenbaum (1994) and
Smith, Mosley, and Booth (1996) profiled some of the most widely accepted self-report
and diagnostic instruments used by clinicians to screen individuals for depression in
primary care setting; some of these are listed in Table 2.

TABLE 2: DIAGNOSTIC INSTRUMENTS

Self-Report Instruments

Diagnostic Tools

(For screening individuals for depression in

(These scales require a trained interviewer to
primary care settings):
administer):
1. General Health Questionnaire (GHQ)
1. Diagnostic Interview Schedule (DIS)(Robins
(Goldberg, 1972)
et al. 1981)
2. Beck Depression Inventory (BDI) (Beck, et 2. Hamilton Rating Scale for Depression
al., 1961; Beck, 1972)
(HRSD)(Hamilton, 1986)
3. Zung Self-Rating Depression Scale
3. Inventory of Depressive Symptomatology
(ZSRDS) (Zung, 1975)
Clinician Rated (IDS-C)(Rush et al., 1986;
4. Center for Epidemiological Studies
Rush et al., 1996)
Depression Scale (CES-D)(Radloff, 1977)
Client Self-Report Measures
1. Inventory to Diagnose Depression (IDD)(Zimmerman, Coryell, Stangle et al., 1986; Rush et al.,
1996)
2. The Depression Outcomes Modules (DOM) Depression-Arkansas Scale (D-ARK)(Smith et al.,
1994)
3. Inventory of Depressive Symptomatology Self-Report (IDS-SR)(Rush et al., 1986; Rush et
al., 1996)
GENERAL TREATMENT OVERVIEW
The five formal treatments for adults with depressive disorders include pharmacotherapy,
psychotherapy, a combination of both, electroconvulsive therapy (ECT) and light
therapy. Medications have been shown to be effective in all forms of depression, yet no
one antidepressant medication is clearly more effective than another is and no single
medication results in remission for all patients.
Some patients cannot tolerate medications due to physical conditions, some simply do not
wish to take medications or do not respond to medication, and others may request
psychotherapy as the first-line treatment. Psychotherapy alone may reduce the symptoms
if the depression is mild to moderate, non-psychotic, not chronic and not highly recurrent.
The combination of medication and psychotherapy may prove beneficial to individuals
with a history of chronic psychosocial problems who have responded partially to either
medications or psychotherapy alone, and/or with a history of treatment adherence
difficulties. Medication is indicated for severe and psychotic depression. ECT is
indicated for patients suffering from severe or psychotic forms of depression with
intense, prolonged symptoms associated with neurovegetative symptoms; for patients
who are significantly functionally impaired who have not responded to adequate trials of
medications or other therapies, or cannot tolerate medications; and, those who are at an
imminent risk for suicide. Light therapy is considered for mild to moderately severe
forms of seasonal, non-psychotic, depressive winter episodes.

CRIME-SPECIFIC TREATMENT FOR DEPRESSION

Currently, there is no literature on the treatment of depression specific to crime victims.
However, many studies have shown that trauma-specific treatment approaches (e.g.,
focusing on posttraumatic stress symptoms like avoidance and re-experiencing while
addressing cognitive distortions) used with individuals suffering from posttraumatic
stress symptoms are effective in reducing concurrent depressive symptoms. It is
recommended that a trauma-specific approach be initially used for individuals displaying
depressive symptoms.
If the individual does not experience relief of depressive symptoms, then a more specific
psychotherapeutic approach, e.g. Cognitive Behavioral Therapy (CBT) or Interpersonal
Therapy (IPT) is indicated. The rationale for the use of CBT to treat depression is based
on the idea that depressed patients have a distorted view of themselves, the world, and the
future. CBT techniques aim to identify and counteract these cognitive distortions and
mis-attributions. The IPT approach aims at clarification and resolution of grief-related
problems, interpersonal roles, role disputes and transitions, and interpersonal difficulties.
Presumably the mild depressive syndromes associated with grief and trauma distress will
be focused on the memory of the crime. Symptoms will be less pervasive and will be
addressed by the individual or group therapy that focuses on the grief related (dynamic)
symptoms in these depressed, grief stricken subjects (Pasternak et al., 1991). This study
highlights the intuitive clinical wisdom of remaining flexible and inclusive with clinical
interventions.

3. ASSESSMENT AND MANAGEMENT OF DEPRESSIVE DISORDERS IN

ADOLESCENTS AND CHILDREN
Very little evidence-based research has been conducted on child and adolescent
depressive disorders. Most of the studies regarding treatment and efficacy data have been
based on clinical experience or have involved adults. None of the research has
specifically involved child or adolescent victims of crime. Therefore, caution should be
used when applying adult research to children.
DETECTION, DIAGNOSIS AND ASSESSMENT
Depressive disorders in youth are often recurrent and accompanied by co-morbid
conditions, poor psychosocial outcome and high risk of suicide and substance abuse,
therefore the early detection, diagnosis and aggressive treatment of these disorders is
critical. It is important to assess for symptom clusters that define subtypes of depression
like seasonality, atypical symptoms, and psychosis in order to develop an appropriate
treatment plan. The most useful diagnostic tool for clinicians is the comprehensive
diagnostic evaluation, including interviews with child, caregivers, and other collateral
sources. The psychiatric assessment of depressed children and adolescents should be
conducted by a trained clinician that is aware of the developmental and cultural factors

that may significantly impact a childs presentation. Lifetime mood charts and mood
diaries can be used to document the longitudinal course of depression.
GENERAL TREATMENT OVERVIEW
Psychotherapy is considered appropriate for all children and adolescents diagnosed with
depressive disorders. Antidepressant medications are helpful in some cases, especially
when patients are not responding to an adequate trial of psychotherapy and/or display
severe depression. Opinions among clinicians vary regarding treatment planning and
treatment duration, however. It is agreed that all interventions should be adapted to the
developmental stage of the child or adolescent and be provided in the least restrictive
setting for the child.
It is important for a treatment plan to match the intent of treatment to the severity of
symptoms. Multiple sessions per week may be warranted during the acute treatment
phase. The inclusion of caregivers in treatment is strongly recommended to facilitate the
resolution of depressive symptoms. It is critical to foster an effective therapeutic rapport
and alliance early in treatment so as to maintain and increase family involvement over the
treatment course.
A clinician should provide education to the child and all family members regarding the
disorder and treatment to decrease mis-attributions made by children and caregivers (i.e.
self-blame: Its all my fault. Im a bad parent. Or blaming the child: Its my kids
fault, hes just lazy or manipulative.). Psycho-education enhances the team approach
and overall compliance with treatment. Furthermore, parental mental health issues should
be addressed.
If warranted parents should be offered the appropriate treatment.
TREATMENT LITERATURE AND RECOMMENDATIONS
There is controversy regarding whether psychotherapy, pharmacotherapy or a
combination should be offered as first-line treatment for children and adolescents
suffering from MDD. In fact, there is a debate regarding which psychotherapies or which
parts of the psychotherapies are most efficacious. Several factors should be considered
when choosing the initial acute therapy: (1) severity, (2) number of prior episodes, (3)
chronicity, (4) subtype, (5) age of the patient, (6) contextual issues (family conflict,
academic problems, exposure to negative life events), (7) compliance with treatment, (8)
previous response to treatment and (9) the patients and familys motivation for treatment
(AACAP, 1998 p. 72). Other factors that also influence the selection and outcome of
treatment are clinician availability, motivation, and expertise with a specific therapy.
Drawing from clinical experience and the few randomized treatment studies done with
children and adolescents, psychotherapy has shown to be a helpful initial acute treatment
for mild to moderate treatment modalities like psychodynamic psychotherapy,
Interpersonal therapy (IPT) and family therapy have been proven effective and are often

10

used clinically. The rationale for the use of CBT for depression is based on the idea that
depressed patients have a distorted view of themselves, the world, and the future. CBT
approaches teach children how to identify and counteract these inaccurate belief systems
and mis-attributions. Continuation therapy is recommended when using CBT with
children because clinical studies have shown a high rate of relapse upon follow-up.
The IPT approach, which focuses on interpersonal roles, role disputes and transitions and
interpersonal difficulties, has been shown to be useful in the acute treatment phase with a
low relapse rate. Psychodynamic therapy can help children better understand themselves,
identify feelings, challenge maladaptive behavior patterns, improve communications with
others, and gain coping skills. More research comparing these therapies is needed to
better understand their effects. See reviews by Bemporad, (1994) and Birmaher et al.,
(1996b) for further discussion on psychotherapeutic techniques used with depressed
children.
Antidepressant medication may be indicated for children and adolescents with depression
of enough severity to interfere with academic and social functioning and the prevention
of effective psychotherapy, and depression that fails to respond to an adequate trial of
psychotherapy. Tricyclic Antidepressants (TCAs) and Selective Serotonin Reuptake
Inhibitors (SSRIs) are the most commonly used medications with depressed children and
have yielded conflicting results. The few studies that have been conducted on the use of
these medications are open or methodologically flawed. Double-blind trials have shown
no significant differences between TCAs and placebos. Overall, children and adolescents
respond at a high rate to placebos.
Due to the positive results of SSRIs with adults with MDD, these medications are now
commonly used to treat depressed children. To date, SSRIs are considered the
antidepressants of choice for children needing medication because they are relatively
safe due to their very low lethality after overdose, have a good side effects profile, are
easy to administer (once a day), and can be maintained on a long-term basis.
Pharmacotherapy alone is never considered a sufficient treatment. Pharmacotherapy
combined with psychotherapy is recommended. A combined treatment approach not only
stabilizes the patients mood, but enhances the likelihood of alleviating depressive
symptoms, improving self-esteem, enhancing coping skills and adaptive strategies, and
improving relationships with family and peers (AACAP, 1998). The high degree of comorbidity and psychosocial and academic problems caused by depression support the use
of multimodal treatment approach.
Continuation therapy lasting for at least six months is recommended for all children and
adolescents being treated for MDD. Continued treatment is supported by the high rate of
relapse and recurrence of depression. After child patients have been asymptomatic for 612 months, the clinician must determine whether or not to continue therapy on a
maintenance basis in order to prevent recurrence. Maintenance therapy is supported for
patients with multiple or severe depressive episodes and those at high risk for recurrence.
For example, patients who have a family history of Bipolar Disorder or recurrent

11

depression, co-morbid psychiatric disorders, or are currently in a stressful and nonsupportive living environment are potential candidates for maintenance therapy.
CRIME-SPECIFIC TREATMENT FOR DEPRESSION
As with adult crime victims, trauma-focused treatment (e.g., addressing PTSD symptoms
and cognitions) produces improvement in childhood depressive symptoms. It is
recommended that this be the first-line treatment. When symptoms do not abate or the
child deteriorates or becomes suicidal, a shift to standard psychotherapeutic approaches is
indicated.

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RELATED READING
Anderson, J.C., and McGee, R. (1994). Co-morbidity of Depression in Children
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Jacobson, N.S., and Hollon, S.D. (1996). Cognitive-Behavior Therapy Versus

Pharmacotherapy: Now That the Jurys Returned Its Verdict, Its Time to Present the
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Shulberg, H.C., Block, M.R., Madonia, M.J., Scott, C.P., Lave, J.R., Rodriquez,
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