Johns Hopkins psychiatrists point to the need for earlier, faster-acting treatments.
Depression is a major source of impairment and suffering in adolescence and is considered an important risk factor for suicide. The good news is that, when identified early, it is treatable through available medications and psychotherapy. These are among the messages of a new review paper in the New England Journal of Medicine by Johns Hopkins psychiatrists Leslie Miller and John Campo.
There has been an increasing prevalence of adolescent depression since the journal’s previous review on the topic was published two decades ago, says Miller, an associate professor of psychiatry and behavioral sciences and director of the Mood Disorders in Adolescents and Young Adults Program.
“Assessing for and identifying adolescent depression earlier in its course will lead to better outcomes,” she says. Untreated depression can last upwards of half a year — enough to lead to a loss of developmental milestones, she notes.
“We know a lot more each year about the management of depression in young people,” adds Campo, the Leonard and Helen R. Stulman Professor and director of the Division of Child and Adolescent Psychiatry, and director of mental health for the Johns Hopkins Children’s Center. “Our approach to depression in adolescents has become increasingly more standardized. We figured out there is a benefit to antidepressant treatment, and there’s a benefit to certain specific psychotherapies, most notably, cognitive behavioral therapy and interpersonal psychotherapy.”
The gold standard for pharmacotherapy has remained treating adolescent patients with an optimal dose of a serotonin-reuptake inhibitor (SSRI) for a minimum of six to eight weeks to achieve efficacy, and to keep them on the medication for a minimum of six months to a year, Miller says. If patients don’t respond to the initial SSRI medication, psychiatrists often try a different SSRI.
In the psychotherapy realm, cognitive behavioral therapy focuses on the role of thoughts, feelings and behaviors, and their interactive effect in maintaining or reducing depression. Adolescents are taught to identify negative thoughts and reframe them. Interpersonal psychotherapy, which focuses on the relationship between depression and interpersonal interactions, teaches patients to recognize their emotions and work to enhance communication and problem-solving skills.
But there are some interventions in need of improvement, says Campo.
“One of the things that this article highlights is the need for interventions that work more rapidly,” Campo says. SSRIs may take several weeks to show effect. “When you’re dealing with a patient who’s really in distress, having an intervention that can act more rapidly could be invaluable and lifesaving.”
Other areas being investigated for adolescent depression include pharmacogenetics; diet and nutrition; the use of ketamine for rapid improvement in depression and suicidal thoughts; and the neuromodulation treatment transcranial magnetic stimulation, the review notes.