Depression: Parents' Medication Guide

Depression: Parents’ Medication Guide Depression Parents’ Medication Guide Work Group CHAIR: Graham J. Emslie, MD

MEMBERS: Teri Brister, PhD, LPC, Representative from National Alliance on Mental Illness Meredith Chapman, MD Mina K. Dulcan, MD Cathryn A. Galanter, MD Jessica M. Jones, MA, LPA Beth Kennard, PsyD Jerry Pavlon-Blum, Representative from Depression and Bipolar Support Alliance Theodore A. Petti, MD, MPH Adelaide S. Robb, MD Timothy E. Wilens, MD

STAFF: Carmen J. Head, MPH, CHES, Director, Research, Development, & Workforce Sarah Hellwege, MEd, Assistant Director, Research, Training, & Education

CONSULTANT: Esha Gupta, Medical Science Writer

The American Academy of Child and Adolescent Psychiatry promotes the healthy development of children, adolescents, and families through advocacy, education, and research. Child and adolescent psychiatrists are the leading physician authority on children’s mental health.

Introduction...... 4

Causes and Symptoms...... 5

Diagnosing Depression in Children and Adolescents...... 6

Suicide and Youth with Depression...... 7

Treating Depression...... 8

Taking Medication for Depression...... 9

Psychosocial Treatments for Depression...... 13

Other and/or Unproven Treatments for Depression...... 14

Helping the Depressed Child...... 15 Introduction

he original Parents Medical Guide on Depression is a type of mood disorder that can treating depression was published in damage relationships among family members T 2005, and a revision was published in and friends, harm school performance, 2010, through collaboration by the American and limit other educational opportunities. Academy of Child and Adolescent Psychiatry Depression can negatively affect eating, (AACAP) and the American Psychiatric sleeping, and physical activity. Because it Association (APA). The current revision has can result in so many health problems, it is been updated to include new research on important to recognize the signs of depression effective treatments for child and adolescent and get the right treatment. When depression depression. The goal of this guide is to help is treated successfully, most children can get parents make informed decisions about back on track with their lives. getting the best care for a child or adolescent with depression. Although depression can occur in young children, it is much more common in What is depression? adolescents (youth ages 12–18 years). Depression is a serious illness that can affect Depression before children reach puberty almost every part of a young person’s life occurs equally in boys and girls. After puberty, and significantly impact his or her family. depression is more common in girls.

4 Depression: Parents’ Medication Guide Causes and Symptoms

Why does my child • Difficulty falling asleep and/or staying • Irritable or cranky mood asleep or sleeping too much have depression? • Boredom, giving up favorite activities, We don’t fully understand all the • Restlessness, unable to sit still (referred toys, and interests causes of depression; we think it’s a to as psychomotor agitation), or combination of genetics (inherited traits) being slowed down (referred to as • Failure to gain weight as expected and environmental factors (events and psychomotor slowing) surroundings). There is no single cause. • Delays in going to sleep, refusal to wake Stressors or events that cause a stressful • Fatigue or loss of energy up for school or get out of bed response and genetic factors can cause Difficulty sitting still or very depression. Stressors can be triggers • Feelings of worthlessness or excessive • slowed movements that result from pediatric illnesses and or inappropriate feelings of guilt diseases, such as viral infections; diseases Difficulties in concentrating or • Tired all the time, feeling “lazy” of the thyroid and endocrine system; head • making decisions injury; epilepsy; and heart, kidney, and lung • Self-critical or blaming self diseases. A family history of depression • Constant thoughts of death, suicidal for everything is a major genetic factor; a child can be thinking, or a suicide attempt more prone to becoming depressed if • Decline in school performance, failing a parent or sibling has been diagnosed According to the Diagnostic and grades or classes with depression. Stressors in everyday Statistical Manual of Mental Disorders Frequent thoughts and discussion about life also contribute to the development (DSM-5), an episode of major depression • death, giving away favorite belongings of depression, for example, the loss of a is characterized by 5 or more of these close loved one; parents frequently arguing, symptoms (with at least one of the separating, or divorcing; school changes; symptoms noted as a depressed and/ How do the symptoms of and family financial problems. Finally, or irritable mood or having reduced depression differ from developmental factors, such as learning interests or little pleasure) that have typical sadness? and language disabilities, are sometimes lasted for at least 2 weeks and affected It is normal for children and adolescents overlooked. Other mental illnesses and a child’s performance at school, at to feel sad sometimes or be irritated symptoms, such as attention-deficit/ work, with family, or with friends. in response to stressors. Depression hyperactivity disorder (ADHD), anxiety, These symptoms are not caused by is different from occasional sadness. fears, and excessive shyness, in addition medication, drug abuse, or alcohol and A child or adolescent with depression to not having opportunities to develop are not the result of another medical or has a significant change in their typical interests and show strengths and talents, mental illness. mood and interest level and is persistent can add to depression. (ie, most of the time for several weeks). The symptoms of major depressive Youth with depression show symptoms disorder (MDD) in youth and adults What are the symptoms that are significant enough to cause them are the same. However, the symptoms problems at home, at school, and/or with of depression? of depression may look differently friends and family. Youth with depression • Depressed, sad, or irritable mood in children and adolescents than in may report that their symptoms are in adults. For example, children may have Significant loss of interest or pleasure response to a stressful or upsetting event, • difficulty expressing their sad mood in activities or they may not know what caused them and may complain of headaches or to feel this way. • Significant weight loss, weight gain, or stomachaches instead. Listed below are appetite changes other ways that depression may look differently in youth:

Depression: Parents’ Medication Guide 5 Diagnosing Depression in Children and Adolescents

How is depression in children and families. Child and adolescent psychiatry adolescents diagnosed? training requires four years of medical school, at least three years of residency training in If you are concerned that your child is general psychiatry with adults, and two years depressed, it’s important to discuss this of additional specialized training in treating with your child’s doctor. Your child’s doctor children, adolescents and families. may recommend a thorough assessment. A thorough assessment includes getting A medical history and physical exam, as well as information about the degree and severity a detailed history of biologically related family of symptoms, psychosocial stressors and members, are also recommended to rule out or functioning from the child, parent, caregiver identify other co-existing medical and mental and/or guardian who lives with the child and health conditions that may require treatment. reports from the school.

This assessment should be done by What other conditions can someone with experience in evaluating accompany depression? children for mental illness, such as a child Up to 50% of children and adolescents diagnosed and adolescent psychiatrist. A child and with depression may have other mental health adolescent psychiatrist is a doctor who disorders, including bipolar disorder. Children specializes in the diagnosis and treatment of and adolescents with depression may also have disorders of thinking, feeling and/or behavior anxiety, ADHD, and learning differences or be at affecting children, adolescents and their risk of abusing drugs or alcohol.

If you are concerned that your child is depressed, it’s important to discuss this with your child’s doctor.

6 Depression: Parents’ Medication Guide Suicide and Youth with Depression

outh with depression are at diseases in children and adolescents. of suicidal thoughts and/or behaviors in increased risk for suicide attempts More adolescents and young adults die youth who take antidepressants. There Y and suicide. It is important to from suicide than from cancer, heart was no record of completed suicides in their ask your child whether they are having disease, AIDS, birth defects, stroke, review of over 2,000 youth who were treated thoughts about hurting themselves. If pneumonia, influenza, and chronic lung with antidepressant medications, but the your child expresses suicidal thoughts, disease combined. rate of suicidal thinking/behavior (including this is an opportunity to discuss actual suicide attempts) was twice as high taking precautions to make the child’s What factors other than in youth taking medications (4%) than those taking placebo or sugar pills (2%). environment safe. Talking with your child depression may increase about suicide does not cause suicide, but it does let your child know that you are suicide risk? Treating underlying depression in concerned and that you want to know Additional risk factors for suicide include youth who are thinking about suicide is an important strategy, because whether they have any thoughts about it. having a family member who died by suicide or knowing someone else who antidepressant medications improve depressive symptoms, which is the How common are suicidal died by suicide. Other factors include family conflict, sleep problems, substance best way to treat suicidal thoughts and thoughts, behaviors, and use, school problems, impulsivity, other behavior. Antidepressant medication may death by suicide in youth? mental illnesses, not feeling connected to increase the risk for suicidal thoughts Among students in grades 9–12 in the others, and easy access to lethal means and/or behaviors in a small percentage United States in 2015, 18% reported of self-harm. of youth. If a doctor determines that seriously considering attempting suicide medication is appropriate for your child, in the previous 12 months, whereas Do antidepressant medications it is important to weigh the pros and 15% actually made a suicide plan. Nine cons of antidepressants. If your child has percent of students attempted suicide increase the risk of suicide? moderate to severe depression, the benefit one or more times, and 3% made Determining whether antidepressant of reducing depressive symptoms may an attempt that resulted in an injury, medications increase the risk for suicide outweigh the risks of medication side poisoning, or an overdose that required is quite hard, particularly because children effects. Maintaining regular follow-ups and medical attention. and adolescents with depression are more monitoring throughout treatment helps likely to think about suicide and attempt it manage any uncertainty. It is important In 2015, suicide was the third leading than other children. With this concern, the that your child be monitored closely for cause of death among youth between the FDA (US Food and Drug Administration) all side effects, including suicidal thinking ages of 10 and 14 years and the second reviewed all published and unpublished and behavior, particularly in the first few leading cause of death among individuals clinical trials of antidepressants in children weeks after beginning treatment with an between the ages of 15 and 34 years. and adolescents, and in 2004, it issued a antidepressant and after adjusting the Suicide claims more lives than many black box warning about an increased risk antidepressant dose.

Depression: Parents’ Medication Guide 7 Treating Depression

he first step to treatment is a thorough stressors, if possible. If your child’s depressive assessment. Once your child has been symptoms get worse or do not improve, his or T diagnosed with depression, there are her doctor may recommend that you consider several important factors to consider before specific treatment, such as psychotherapy and/ moving forward with treatment. It is important or antidepressant medications for your child. to get as much information as possible from your child’s doctor on effective treatment The primary goals of treatment are as follows: 1) to shorten the duration of your child’s options, potential side effects, and treatment depressive episode; 2) to provide treatment expectations. You and your child should until your child’s symptoms are in remission have the opportunity to ask questions about (having minimal or no depressive symptoms); treatment options before you make a decision and 3) to prevent relapse or recurrence about your child’s care. (a return of depressive symptoms). It is important to share with your child’s doctor your understanding of depression and related Will my child’s depression pass treatment options. Family values and norms— without treatment? which can be heavily influenced by ethnicity A single episode of depression, if left untreated, and culture—may play a role in decision often lasts from 6 to 9 months, which can making regarding your child’s wellness. be an entire school year for most children. When left untreated, the consequences can If your child’s depression is not so severe be serious, including a high risk for substance or does not significantly impair his or her abuse, eating disorders, teenage pregnancy, functioning and they do not have suicidal and/or suicidal thinking and behaviors. Suicide thoughts or psychosis, your child’s doctor may attempts and completed suicide are risks of recommend active support and monitoring. untreated depression. Children with untreated During a period of active support and depression are also likely to have ongoing monitoring, it is important for your child to have problems in school, at home, and with their positive interactions with peers, to exercise, A single episode of friends; it can also lead to a higher risk of to follow a healthy diet, and to practice good developing a more chronic, difficult-to-treat depression, if left sleep patterns. It is also important to reduce form of depression. untreated, often lasts from 6 to 9 months, which can be an entire school year for most children.

8 Depression: Parents’ Medication Guide Taking Medication for Depression

Are medications effective for caregiver’s preference for treatment with depression in youth? medication, psychotherapy, or combined psychotherapy and medication treatment. Antidepressant medications can be effective in relieving depressive symptoms in children Selective Serotonin and adolescents. Approximately 55–65% of Reuptake Inhibitors (SSRIs) children and adolescents will respond to initial Medications called SSRIs are the first-line treatment with antidepressant medication. Of treatment for youth with depression. those who don’t respond to the first treatment, a high number will respond to another SSRIs work by increasing the levels medication and/or a different form of therapy, of serotonin in the brain. Serotonin is such as cognitive-behavioral therapy (CBT) or a neurotransmitter that sends signals dialectical behavior therapy (DBT). between brain cells. It is common to experience side effects from SSRIs right What types of medications after beginning treatment; it can take up are available to treat my to 4 to 6 weeks of taking an SSRI regularly child’s depression? for the medication levels in the brain to be steady enough to decrease the symptoms To date, fluoxetine [a selective serotonin of depression. SSRIs are also used for reuptake inhibitor (SSRI), also known as treating conditions other than depression, Prozac] is the only antidepressant approved such as anxiety disorders. by the FDA for the treatment of depression in both children and adolescents (ages 8 years The table on page 10 includes the and older). Escitalopram (an SSRI also known most commonly used SSRIs for youth as Lexapro) is approved by the FDA for the with depression. treatment of depression in adolescents (ages 12 years and older). No other antidepressants Other Antidepressants have been approved by the FDA for the Although SSRIs are usually the first choice treatment of depression in youth, although of medication for children and adolescents some have been approved for the treatment with depression, your doctor may recommend of other mental health conditions. Your child’s different types of medications if in certain doctor may prescribe other antidepressant circumstances, such as your child does not medications that are not FDA approved based improve with an SSRI. These medications Medications called on available data. You should know that have unique qualities that make them prescribing an antidepressant that has not effective, some of which involve serotonin SSRIs are the first-line been approved by the FDA for use in children and other neurotransmitters. The table on treatment for youth and adolescents (referred to as off-label use or page 10 includes non–SSRI antidepressants prescribing) is common and is consistent with that are approved by the FDA for adults with with depression. accepted clinical practice. depression and are often prescribed for youth with depression in clinical practice. Factors that might influence a doctor’s choice(s) of medication include, but are not Other prescribed antidepressant medications, limited to, specific characteristics of the such as tricyclic antidepressants (TCAs, patient, comorbid or coexisting mental or eg, imipramine and amitriptyline) and older medical conditions, and patient or parent/ monoamine oxidase inhibitors [MAOIs, eg,

Depression: Parents’ Medication Guide 9 or has not responded to treatment. SELECTIVE SEROTONIN REUPTAKE INHIBITORS Other types or classes of medications, Medication Formulations Daily Dose Range particularly mood stabilizers and atypical Citalopram (Celexa) Tablet: 10/20/40 mg 10–40 mg antipsychotic medications, may also Suspension: 10 mg/5 ml improve the effects of antidepressant Escitalopram (Lexapro)* Tablet: 5/10/20 mg 10–20 mg Suspension: 1 mg/1 ml (initial dose may be 2.5–5 mg) medications, but they are not used as often because of the risk of more serious Fluoxetine (Prozac)** Tablet and capsule: 10/20/40/60 mg 20–60 mg Suspension: 20 mg/5 ml (initial dose may be 10 mg) side effects like weight gain, obesity, and Fluvoxamine (Luvox) Tablet: 25/50/100 mg 50–200 mg metabolic syndrome. (initial dose may be 25 mg) Paroxetine (Paxil) Tablet: 10/20/30/40 mg 10–50 mg Side Effects Tablet CR: 12.5/25/37.5 mg Suspension: 10 mg/5 ml The most common side effects of SSRIs are as follows: Sertraline (Zoloft) Tablet: 25/50/100 mg 50–200 mg Suspension: 20 mg/ml (initial dose may be 12.5–25 mg) gastrointestinal symptoms (nausea, Note: CR = controlled release • *FDA approved for children age 12 and up. stomachaches, and/or diarrhea) **FDA approved for children age 8 and up. • headaches NON–SSRI ANTIDEPRESSANTS • agitation Medication Formulations Daily Dose Range sleep disturbance Bupropion, Bupropion SR Tablet: 75/100 mg 150–300 mg • (Wellbutrin) Tablet ER 12 hour: 100/150/200 mg (first dose may be 37.5–75 mg) irritability Bupropion XL (Wellbutrin) Tablet ER 24 hour: 150/300/450 mg 150–450 mg • Desvenlafaxine (Pristiq) Tablet ER 24 hour: 25/50/100 mg 50–100 mg activation (first dose may be 25–50 mg) • Duloxetine (Cymbalta) Tablet: 20/30/40/60 mg 40–60 mg Sexual side effects, increased bruising (first dose may be 20 mg) and/or bleeding, and mania are also Levomilnacipran (Fetzima) Capsule ER 24 hour: 20/40/80/120 mg 40–120 mg (first dose may be 20 mg) possible, although they are less Mirtazapine (Remeron) Tablet: 7.5/15/30/45 mg 15–45 mg common side effects of SSRIs. The Tablet disintegrating: 15/30/45 mg (first dose may be 7.5–15 mg) most common side effects of non–SSRI Trazodone (Desyrel) Tablet: 50/100/150/300 mg 100–150 mg (first dose may be 25–50 mg) antidepressants vary quite a bit among Venlafaxine XR (Effexor) Tablet: 25/37.5/50/75/100 mg 150–300 mg the individual medications. If your Capsule and (first dose may be 37.5 mg) child has been prescribed a non–SSRI Tablet ER 24 hour: 37.5/75/150/225 mg antidepressant, you should ask your Vilazodone (Viibryd) Tablet: 10/20/40 mg 15–40 mg (first dose may be 10 mg) child’s doctor about the side effects that Vortioxetine (Trintellix) Tablet: 5/10/20 mg 20 mg (first dose may be 10 mg) are specific to that medication. Note: SR = sustained release, ER = extended release, XL = extended release, XR = extended release Some side effects may be managed easily. For example, if your child experiences phenelzine (Nardil) and tranylcypromine the side effect of sleepiness throughout (Parnate)], are not recommended as the day, it may be wise to take the a first-line treatment for youth with antidepressant at bedtime, or if your child depression because they have not experiences nausea as a side effect, it been proven to be effective and have might be helpful to take the antidepressant negative side effects. A newer MAOI with meals. If your child experiences called selegiline (Emsam) appears to side effects from one SSRI, they will not be as good as other antidepressants in necessarily experience the same side treating adults with depression, with few effects from all SSRIs, so it is important negative side effects. Although selegiline for you and your child to discuss all of their was not shown to be effective in treating side effects with their doctor. It is important adolescents with depression, it was safe to contact your child’s doctor immediately if and well tolerated in a recent study. your child experiences any unusual change in behavior at any time after starting Sometimes more than one antidepressant treatment with an antidepressant. medication may be prescribed for a youth who has shown only partial response to Serotonin syndrome is a rare but serious initial treatment, has lingering symptoms, potential side effect of SSRIs. Serotonin

10 Depression: Parents’ Medication Guide syndrome occurs when high levels of attention to any signs of increased anxiety, • You should work with your child’s doctor serotonin accumulate in the body, and agitation, aggression, or impulsivity. or other mental health provider to it most often happens when a person is Parents should also check their children develop an emergency safety plan, which taking more than one medication that for involuntary restlessness or unexplained consists of a planned set of actions for affects the serotonin level. Symptoms of happiness or energy accompanied by fast, you, your child, and your child’s doctor to serotonin syndrome may include fever, driven speech, and unrealistic plans or take if your child has more thoughts of confusion, tremor, restlessness, sweating, goals. These reactions are more common suicide. This should include access to a and increased reflexes. at the start of treatment, but they can 24-hour crisis phone number available to occur at any time during treatment. If your deal with such crises. Other medications, in addition to those child shows any of these symptoms or that affect serotonin, can interact with If your child expresses new or more any other concerning changes in behavior, • SSRIs and other antidepressants and frequent thoughts of wanting to die or consult your child’s doctor immediately, cause problems. Therefore, it is very self-harm or takes steps to do so, you because it may be necessary to adjust the important that you tell your child’s should implement the safety plan and doctor about all the medications and dose, change to a different medication, or contact your child’s doctor immediately. supplements that your child takes. It is stop using the medication. also important to discuss with your child’s The following precautions for suicide How do I know if my child’s doctor any new supplements or over- prevention should be put into place if a medication is working? the-counter medications or medications child or any other family member You may notice that your child’s prescribed to your child by other doctors has depression: medication is working if your child’s before taking those medications. depressive symptoms (mood, interest, • Dangerous means of suicide, such appetite, sleep, concentration, or suicidal How can I help monitor my as guns, should be removed from thinking/behavior) improve or if they are child during treatment? the home, and potentially dangerous functioning better at school, at home, Because some youth have adverse medications, including over-the-counter or with peers. Your child’s doctor will physical and/or emotional reactions to drugs like acetaminophen (Tylenol) know whether your child’s medication is antidepressants, parents should pay should be locked away. working by collecting information from

Depression: Parents’ Medication Guide 11 you, your child’s school team, and your why and address the cause. In addition child through clinical assessments and to problems with finding the right dose self-reports and parent questionnaires or the duration of medication therapy, and other reports. nonresponse may be the result of a number of other factors, including wrong It is important for your child to have diagnosis, another medical illness, more frequent visits with their doctor extreme stress, poor management of soon after they start their treatment comorbid mental conditions, or not with an antidepressant. More frequent properly following the instructions on visits early in treatment and during taking the medication. If your child does times of antidepressant medication not respond to a first SSRI, your child’s dose adjustments will allow your child’s doctor might recommend a second SSRI. treatment provider to address any Research has shown that approximately concerns about treatment response or half of youth who don’t respond to one side effects and to monitor your child for SSRI will still respond to a second SSRI. suicidal thinking and behavior. If your child does not respond to a second SSRI, non–SSRI antidepressants What can be done if my are then considered. child’s depression is not improving on medication? Once my child is well, how Depending on the specific antidepressant long do they need to continue that your child is taking, it may take 4–6 weeks of treatment before your child’s taking medication? depressive symptoms begin to show If your child responds to treatment improvement. This may be the case, even with an antidepressant, which is when if your child started to have side effects depressive symptoms are reduced by shortly after taking an antidepressant for 50% or more, it is recommended that the first time. If your child’s depressive they continue taking antidepressants symptoms have not improved after taking for 6–12 months after achieving this an antidepressant regularly for 4–6 weeks, response. Youth who don’t continue their doctor may consider increasing treatment, especially if they still have the antidepressant dose. An appropriate leftover symptoms, are at increased risk trial of an antidepressant may last up of sinking back into depression. to 12 weeks. If your child’s depressive Six to 12 months after responding to symptoms have not responded to an treatment, stopping antidepressants adequate trial of an antidepressant or medication may be the right choice for if your child experiences unacceptable side effects from an antidepressant, their some youth. Stopping antidepressant doctor may recommend switching to a treatment should be done only under the different antidepressant or adding an care and monitoring of your child’s doctor. additional antidepressant. Youth who stop taking antidepressants should be reassessed by their doctor When a child or adolescent fails to within 1–2 weeks to check for any respond to treatment with an SSRI, it withdrawal effects and/or return of is extremely important to understand depressive symptoms.

12 Depression: Parents’ Medication Guide Psychosocial Treatments for Depression

What treatments other than shown to be effective in studies. This medication are available to help intervention, which promotes family alliances and connection, builds on family strengths my child’s depression? and also improves the adolescent’s success There is a great deal of scientific support outside of the home. showing the effectiveness of psychosocial treatments for youth with depression. Dialectical Behavior Therapy Cognitive-behavioral therapy (CBT), DBT, originally developed in adults, has recently interpersonal therapy (IPT), and attachment- been adapted for adolescents. It has been based family therapy are several examples. proven to be effective in treating moderate to severe depression and co-occurring disorders, Cognitive-behavioral Therapy along with self-harm and suicidal behaviors. CBT is the most widely studied psychotherapy It was originally based on CBT but it also for the treatment of youth with depression. includes strategies for controlling emotions CBT is a form of psychotherapy that targets and handling stressful situations. thoughts and behaviors that are related to mood. The individual is taught to identify Supplementary Interventions patterns of thinking and behavior that add Other work has focused on using high-dose to their depressed mood. CBT may be used exercise programs to reduce depressive as a form of treatment by itself, or it can be symptoms, improve mood, and reduce combined with antidepressant medication. relapse into depression. Studies have shown There is some evidence that CBT is most that exercise can be an effective way to effective when combined with antidepressant treat depression. Furthermore, interventions therapy, particularly for adolescents with more that improve sleep can also be used to severe depression or in those with treatment- improve depressive symptoms. Motivational resistant depression. Pediatric guidelines say interviewing strategies can be used to that CBT alone may be an appropriate first-line improve adolescents’ participation with all treatment for those with mild depression. interventions and improve their desire to Promoting wellness stick with the treatment program. Interpersonal Psychotherapy and emotional Although there are fewer clinical trials of IPT Although there is little research to support resilience, not just compared with CBT, IPT is a well-established its use to treat depression in children and intervention in adolescents. IPT works by adolescents, psychodynamic psychotherapy reducing depressive focusing on improving relationships with may be a helpful part of an individualized symptoms, is an friends and family, increasing social support, treatment plan for some youth. and improving problem-solving skills. overall goal of positive Promoting wellness and emotional resilience, mental health. Family-based Treatment not just reducing depressive symptoms, is Studies involving family therapy are more an overall goal of positive mental health. difficult to evaluate because of the diversity Strategies focus on youth participating in of interventions. However, one treatment activities that develop self-confidence or a model—attachment-based family therapy— sense of purpose, increase feeling connected has been manualized, meaning that therapists with other people, and foster gratitude or follow the same process, and it has been willingness to help others.

Depression: Parents’ Medication Guide 13 Other and/or Unproven Treatments for Depression

everal herbal supplements on the There are treatments for MDD in youth market (eg, St John’s Wort, etc.) may that are currently being studied under the S claim to treat symptoms of depression; oversight of the FDA, including esketamine however, it is important to understand that and transcranial magnetic stimulation (TMS). there is little scientific research showing These treatments may or may not be available that these supplements work in treating in your area. Youth who do not improve depression. In addition, these supplements clinically during other stages of treatment are not regulated by the FDA or any other may be candidates for such interventions. agency. If you are considering giving your Before starting new or investigational treatment, child herbal supplements, always check with your child’s doctor may consider conducting the doctor as supplements may interact with a reassessment to determine whether the prescribed medications. initial diagnosis was correct, evaluate whether there are ongoing or unrecognized comorbid disorders, and assess how well psychosocial interventions are being implemented.

Several herbal supplements on the market (eg, St John’s Wort, etc.) may claim to treat symptoms of depression; however, it is important to understand that there is little scientific research showing that these supplements work in treating depression.

14 Depression: Parents’ Medication Guide Helping the Depressed Child

What is my role in my Reduce Negative Emotion in the Home child’s treatment? (Sarcasm, Criticism) Having family members in the home who Provide Support and Reduce Stress suffer from depression can be challenging. It is It is important to remember that depression is important to avoid criticism and blame. While an illness, and you will need to provide support, your child is depressed you may consider calling avoid blame, and reduce as much stress as a truce on “hot topics” or subjects that can possible for your child. It will be necessary to lead to high conflict and disagreement. Finding work with your child to review their current activities that the family can do together to schedule and/or activities to determine promote positive emotions and increase activity what might need to be adjusted. It may be level can be helpful. Parents may seek out necessary to modify your expectations for parent psychoeducation or couples therapy, and your child, at least until symptoms improve. you may check to see whether parent coaching When disciplining or punishing your child, is available in the community. The National don’t deny them access to things that make Alliance on Mental Illness (NAMI), Depression them happy or help them cope (eg, don’t take and Bipolar Support Alliance (DBSA), and other away access to friends or extracurricular mental health organizations offer a variety of activities, if possible). As needed, work with options for support and information. Because and involve school professionals to adjust childhood or adolescent depression affects academic workloads, pace, and expectations. the whole household, all family members can Communicate to the teachers and other school benefit from supportive treatment. staff that your child suffers from mental health challenges and that from time to time they may require special accommodations Develop Communication Strategies for learning and/or interaction with peers. When there is conflict and when emotions are Assumptions about what your child can high, developing a solid communication plan manage in school, based only on periods of is recommended. An “exit and wait” strategy good moods (also known as euthymia), should to allow family members to gain control of be strongly avoided. their emotions can help to manage difficult communication and conflict. Help Teenagers Practice New Skills and New Ways of Thinking Participate in Safety Plan; It is important to be involved in your child’s Keep Environment Safe treatment. This includes knowing the new A safety plan that includes strategies for skills/strategies that your child is learning in managing mood, getting support, and knowing treatment. Parents can help to model these when to get professional help is important. skills at home and point out opportunities In addition, making the environment safe to practice and apply them in the home by removing all access to dangerous tools, setting. Some therapists envision the such as medications, knives or other blades, parents’ role as serving as a “coach” to help weapons, and firearms, is an essential part of with learning these strategies and extending treating youth with depression. them to other settings.

Depression: Parents’ Medication Guide 15 Monitoring Social Media, Resources Peer Influence, Social Stress Youth who are depressed can be • American Academy of Child & especially vulnerable to social media and Adolescent Psychiatry (AACAP) conflict with peers. Teenagers may see https://www.aacap.org/aacap/ others as having more friends or more fun Families_and_Youth/Resource_Centers/ than themselves, which may make them Depression_Resource_Center/Home.aspx feel even more excluded or not liked by National Alliance on Mental Illness (NAMI) others. Constantly checking social media • https://www.nami.org/Find-Support/ sites to make sure that they haven’t been Family-Members-and-Caregivers left out can be a source of stress for youth. Parents need to be vigilant and aware of • Depression and Bipolar Support Alliance the impact of social media and peers on (DBSA) http://www.dbsalliance.org/site/ their child. Protective monitoring, such PageServer?pagename=home as having guidelines and rules for using technology, is important. Technological • National Institute of Mental Health tools, such as parental control software, to (NIMH) https://www.nimh.nih.gov/health/ control and monitor use of media are more publications/teen-depression/index.shtml and more available and may be needed https://www.nimh.nih.gov/health/ for youth who are negatively affected by publications/depression-what-you-need- social media and/or cyberaggression or to-know/index.shtml cyberbullying by their peers. • Centers for Disease Control and Is there anything else that I Prevention (CDC) https://www.cdc.gov/ can do to help my child? childrensmentalhealth/depression.html It’s important for parents and caregivers to practice self-care. Find support and learn more about what’s going on with your child so that you can be as effective as possible in helping them get the care they need. The National Alliance on Mental Illness (NAMI), Depression and Bipolar Support Alliance (DBSA), and other mental health organizations offer a variety of options for support and information. Depression tends to run in families, so it’s important to know that if anyone else in the family is experiencing symptoms of depression, they need to also seek treatment.

16 Depression: Parents’ Medication Guide Author Disclosures

MEREDITH CHAPMAN, MD THEODORE A. PETTI, MD, MPH TIMOTHY E. WILENS, MD No disclosures to report President, American Society for Chief, Child and Adolescent Psychiatry Adolescent Psychiatry Department MINA K. DULCAN, MD Co-director, Center for Addiction Medicine Advisor/Consultant: Care Management ADELAIDE S. ROBB, MD Technologies Advisor/Consultant: Allergan, Inc.; Bracket Massachusetts General Hospital Global; Ironshore Pharmaceuticals Inc.; Royalties: American Psychiatric Advisor/Consultant: Euthymics Bioscience; Lundbeck; Aevi Genomic Medicine, Inc.; Association Publishing Neurovance; Otsuka America Pharmaceutical, Neuronetics; National Institute of Mental Inc.; National Institute on Drug Abuse; GRAHAM J. EMSLIE, MD Health; Rhodes Pharmaceuticals; Sunovion Ironshore Pharmaceuticals Inc.; Alcobra Professor, Chief of the Division of Child Pharmaceuticals, Inc.; Tris Pharma; Ltd.; US National Football League (ERM and Adolescent Psychiatry, University of University of Cambridge Associates); US Minor/Major League Texas Southwestern Medical Center Books/Intellectual Property: Guilford Press Baseball; Bay Cove Human Services; Phoenix House and Gavin Foundation Chief of Service, Children’s Medical Center Data and Safety Monitoring Board: Aevi Advisor/Consultant: Assurex Health, Inc.; Genomic Medicine, Inc.; Neuronetics Books/Intellectual Property: Guilford Press; Cambridge University Press; Elsevier Syneos Health; Lundbeck; Otsuka America Honoraria for Speaking at a Meeting: Pharmaceutical, Inc. American Association of Child and Co-owner of a copyrighted diagnostic Research Funding: Duke University, Adolescent Psychiatry; American Academy questionnaire: Before School Functioning Forest Research Institute, Inc. of Pediatrics Questionnaire (BSFQ) In-Kind Services: Allergan, Inc.; Licensing agreement: Ironshore CATHRYN A. GALANTER, MD American Academy of Child and Pharmaceuticals Inc. Training Director, Child and Adolescent Adolescent Psychiatry; American Psychiatry, SUNY Downstate/Kings Research Funding: National Institute on Academy of Pediatrics; The Child County Hospital Drug Abuse and Adolescent Psychiatric Society Advisor/Consultant: The REACH Institute of Greater Washington; Lundbeck; Books/Intellectual Property: American Rhodes Pharmaceuticals; Sunovion Psychiatric Association Publishing Pharmaceuticals, Inc.; Tris Pharma Research Funding: Allergan, Inc.; JESSICA M. JONES, MA, LPA Lundbeck; National Center for Advancing No disclosures to report Translational Sciences; National Institute of Neurological Disorders and Stroke; BETH KENNARD, PSYD Pfizer Inc.; Sunovion Pharmaceuticals, Inc.; Program Director, Clinical Psychology Supernus Pharmaceuticals, Inc.; SyneuRx Graduate Program, University of Texas Southwestern Medical Center Stock in IRA: Eli Lilly and Company; GlaxoSmithKline; Johnson & Johnson School of Health Professions Promotion Services, Inc.; Pfizer Inc. and Tenure Committee, University of Texas Southwestern Medical Center Vice Protocol Chair, CBT Expert–IMPAACT Board of Directors, Jerry M. Lewis, MD, Research Foundation Royalties: Guilford Press

Depression: Parents’ Medication Guide 17 Medication Tracking Form

Use this form to track your child’s medication history. Bring this form to appointments with your provider and update changes in medications, doses, side effects and results.

Date Medication Dose Side Effects Reason for keeping/stopping

18 Depression: Parents’ Medication Guide

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