Enhancing Quality in School Mental Health

Depressive Disorders

Depression in children and adolescence is an area that has received a great deal of study in recent years. The prevalence of depressive disorders in children appears to be rising. There is currently a prevalence of 2% for prepubertal children and approximately 5 % for adolescents.
Nearly one in five high school students has seriously considered taking his or her own life, and suicide is the third leading cause of death among adolescents. In addition to the level of mortality associated with Major Depression, there is also increased morbidity when one considers the poor school performance, strained family relationships, and the loss of productivity when young adults with depression remains untreated or inadequately treated. Because of all the potential negative outcomes for not treating depression, it becomes incumbent upon the mental health professional to know all of the treatment options for depression.
While the author recognizes that there are a number of other behavioral and psychotherapeutic techniques to treat depression in childhood and adolescence, those will not be addressed in this review article about medication management for depression. The article will also not address classes of antidepressants that are no longer commonly used in children such as the tricyclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs), which were discontinued due to potentially dangerous side effects.
The most common medications used to treat depressive disorders are the Selective Serotonin Uptake Inhibitors (SSRIs). SSRIs were first introduced in the United States with the Food and Drug Administration (FDA) approval of Prozac in 1987. Prozac has since gone on to become one of the most commonly prescribed drugs for any disorder, either physical or psychiatric, in history.
The introduction of Prozac- generic names in brackets- (fluoxetine) was followed by other drugs in this class including Zoloft (sertraline), Paxil (paroxitine), Luvox (fluvoximine), Celexa (citalopram), and Lexapro (escitalopram oxalate).
The appeal of SSRIs has been twofold: (1) their effectiveness at treating depression in the vast majority of individuals, and (2) the relatively small number of side effects experience by users when compared to medications available to treat depression prior to the development of SSRIs. The most common side effects of SSRIs include nausea, drowsiness, headache, weight loss, and anxiety/irritability.
Lately, SSRIs have come under increased scrutiny due to recently documented cases of excessive irritability and an increased risk of suicide among children and adolescents. These concerns have led the FDA to place a “black box” warning, meaning that these drugs have an increased risk for these side effects.
However, there are other studies which show no increased risk of suicidal ideation. It should be noted that the “black box” warning was extended to cover all antidepressant use in children and adolescents.
The majority of medications that have been introduce since 1990 work on multiple neurotransmitters (usually seretonin as well as norepinephrine). (continued on reverse)

Depressive Disorders (Continued)

Effexor (venlafaxine) and Cymbalta (duloxetine)are both members of the Serotonoin Norepinephrine Reuptake Inhibitors (SNRIs) class of antidepressants. SNRIs (serotonin-norepinephrine reuptake inhibitors) work on the norepnephrine and the serotonin neurotransmitters. Remeron (mirtazapine) and Trazedone (Deseryl) also increases levels of norepinephrine and serotonin, but it is a tetracyclic antidepressant, not a SSRI or SNRI. The arrival of these new drugs suggest that future antidepressants will not work on serotonin exclusively. Wellbutrin is another effective antidepressant, but it has a unique chemistry that differs from those medications described above. However, this medication should not be used in children with a history of seizure disorder or are at known risk for seizure disorder since Wellbutrin lowers the seizure threshold.
In summary, the treatment of depression in juveniles is critical for their ongoing development and future life success. The newer medications offer relatively safe medication alternatives that should only be one part of a comprehensive treatment plan. Because these medications may have serious and potentially dangerous side effects in a small number of youth, they should be monitored closely by a qualified specialist.
Dr. Kenneth Rogers teaches in the Department of Psychiatry at the University of Maryland, School of Medicine.
Dr. Kenneth Rogers teaches in the Department of Psychiatry at the University of Maryland, School of Medicine.
Dr. Kenneth Rogers teaches in the Department of Psychiatry at the University of Maryland, School of Medicine.

Practice Elements for Depression

This article provides helpful hints for teaching activity scheduling and problem solving skills to students.
Activity Scheduling:
To increase buy-in from students, emphasize the benefits of activity including distraction, increased energy, and pleasure.
Ask students about the activities they once enjoyed but no longer participate in. Remember to include these activities along with those they enjoy right now when selecting activities to include in their scheduling.
Help students go back to participating in activities they once enjoyed by using smaller, neutral steps that seem more manageable.
Remember to plan in advance! Encourage students to write their activity schedule at least a day ahead of time
Problem Solving
An important part of problem solving is being able to accurately identify the feelings and thoughts of one's self and others.
Review a list of 2-3 scenarios and after each have students record their thoughts and emotions on a blank piece of paper. Collect the papers and write all of the emotions for each scenario. This activity highlights how people think differently about the same situation.
Role play different emotions for students (e.g., happy, sad, angry, worried). Ask the students to identify the emotion you display by recording what they see and hear. Paying attention to the actions and words of others helps students become more attuned to their own emotions, as well as the feelings of others.
References
Shure, M.B. (1992). I can problem solve: An interpersonal cognitive problem-solving program. Champaign, IL: Research Press.