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doi: 10.1016/j.psc.2011.12.002

Child and Adolescent Depression: Psychotherapeutic, Ethical, and Related Nonpharmacologic Considerations for General Psychiatrists and Others Who Prescribe

Mary Lynn Dell ab,

a Child and Adolescent Psychiatry Consultation Liaison Service, Rainbow Babies and Children's Hospital/University Hospitals Case Medical Center, Cleveland, OH, USA
b Case Western Reserve University School of Medicine, 10524 Euclid Avenue, W.O. Walker Building, Suite 1155A, Cleveland, OH 44106, USA

Palabras Clave

Children. Adolescents. Depression. Psychotherapy. Ethics. Multidisciplinary treatment.


Depression is among the most common of all illnesses, affecting over 16% of all individuals in the United States at some time in their lives.1 Because of its recurrent nature, treatment resistance, lack of treatment, or a combination thereof, 85% of those with depression will suffer recurrence within 15 years.2 Youth experience depression at significant rates as well. Recently published results from the National Comorbidity Study–Adolescent Supplement reveal a lifetime prevalence of major depressive disorder or dysthymia of 11.2% of 13- to 18-year-olds, with a 3.3% lifetime prevalence of a severe depressive disorder in that same age group.3 The 2008 National Survey on Drug Use and Health, sponsored yearly by the Substance Abuse and Mental Health Services Administration, shows the prevalence of depression among 12- to 17-year-olds to be 8.3%, with girls showing 3 times the prevalence as boys.4 One-year prevalence rates for major depression are approximately 2% in childhood and 4% to 7% in adolescence.5 Depression in adolescence is associated with increased risks of substance abuse and dependence and academic, occupational, interpersonal, and other social difficulties.6, 7, 8, 9 Suicide risk is significantly increased in youth with depressive disorders and is the third leading cause of death in adolescents. Data published by the Centers for Disease Control and Prevention report that over a 1-year period of time studied, 13.8% of American adolescents considered killing themselves, 10.9% had made plans, and 6.3% actually reported attempting suicide.10

Clearly, a large workforce of well-trained, qualified professionals is needed to provide competent care to the millions of youth affected by psychiatric disorders of all kinds, especially child and adolescent depression. Work force issues have been of prime concern in the American Academy of Child and Adolescent Psychiatry (AACAP). The demand for services by child and adolescent psychiatry was anticipated to increase by 100% between 1995 and 2020, and as of 2009 there were an estimated 7,000 practicing child and adolescent psychiatrists practicing in the United States, far short of the 30,000 predicted to have been needed by 2000, 9 years earlier. Recruitment and funding issues make it unlikely that the numbers of these subspecialty physicians will swell to the estimated 13,000 predicted to be needed to meet demand.

In addition, there are significant distribution concerns within the existing pool of child and adolescent psychiatrists. Rural states and impoverished areas, rural or urban, have poor or limited access to child psychiatric services. It is in these geographical areas that general psychiatrists frequently find seriously ill youth on their patient lists simply because they may be the best qualified physician in the region to care for these children and adolescents.11 These statistics also portend that pediatricians, family practitioners, nurse practitioners, and general psychiatrists will be called on to assess and treat pediatric depression with increasing frequency in the years to come.

Although this article, for the sole, practical reason of economy of words, predominantly cites general psychiatrists, it also addresses the needs of other clinicians who prescribe for and participate in the care of depressed children and adolescents.

Adult Psychiatrists Caring for Children and Adolescents: General Considerations

What preparation do general psychiatry trainees receive in anticipation of rising to the challenge of managing child and adolescent disorders? The Psychiatry Program Requirements determined and published by the Accreditation Council for Graduate Medical Education (ACGME) mandates a minimum of 2 months of full-time equivalent of an organized clinical experience. During this experience, residents are to be “supervised by child and adolescent psychiatrists who are certified by the American Board of Psychiatry and Neurology or judged by the Review Committee to have equivalent qualifications; and provided opportunities to assess development and to evaluate and treat a variety of diagnoses in male and female children and adolescents and their families, using a variety of interventional modalities.”12 Settings vary from inpatient, day treatment, and outpatient, and less commonly, residential settings. Court, school, and other consultative experiences are more challenging to arrange at the general psychiatry level of training. Trainees and supervisors alike are wise to consider child elements of the general training program as exposures to the practice of child and adolescent psychiatry that rarely, if ever, substitute for the breadth and depth of training available in 2-year fellowship programs. Regardless, the completion of a general psychiatry training program does provide a foundational experience that may indeed be that primary preparation for generalists who find themselves treating minors, whether by choice or necessity of their practice setting.

Three distinct, but interrelated, funds of knowledge are essentially important for the general psychiatrist caring for children and adolescents. These include normal development, psychopathology, and treatment, especially the principles and practice of psychopharmacology. Without a developmental perspective, the prescribing psychiatrist can appreciate neither the challenges children and families face as they grow and change together, nor psychopathology as it manifests in different age groups and situational contexts. In today's environment of relatively easy access to information, several thorough, clinically helpful reviews of development are available for general clinicians.13, 14, 15, 16 Similarly, several overviews of the psychopathology, assessment, and management of childhood depression are readily available and typically updated every few years.17, 18, 19 Detailed clinical manuals and book chapters on psychopharmacologic treatment of child and adolescent depression are available through several major medical presses and are very helpful resources in clinical work with young patients and their families.20, 21, 22, 23, 24, 25, 26, 27, 28, 29 In addition, the AACAP has helpful documents available in print and online, including approved Practice Parameters for the psychiatric assessment of children and adolescents, the assessment of the family, the assessment and treatment of children and adolescents with depressive disorders, the use of psychotropic medication in children and adolescents, and child and adolescent mental health care in community systems of care (cuadro x1).30, 31, 32, 33, 34

Cuadro x1. AACAP practice parameters relevant to the treatment of child and adolescent depression

1. Current Parameters

a. Depressive Disorders (2007)

b. Assessment of the Family (2007)

c. Community Systems of Care (2007)

d. Physically Ill Children (2009)

e. Prescribing Psychotropic Medication to Children (2009)

2. Parameters in Development or Updates in Progress

a. Assessment of Children and Adolescents (1997–update in progress)

b. Suicidal Behavior (2001–update in progress)

c. Psychodynamic Psychotherapy with Children (new parameter under final review)

From the American Academy of Child and Adolescent Psychiatry. Practice Parameters. Available at: http://www.aacap.org/. Accessed December 7, 2011.

In many ways, the objective, evidence-based tasks of child and adolescent psychiatry, such as assessment, diagnosis, and medication management are more straightforward and less daunting than in years past. More information is readily available in print and on the internet. Furthermore, telephone consultation can be arranged with experts across the country, and telepsychiatry is becoming increasingly popular with patients and clinicians alike.35 For the general psychiatrist treating children and adolescents, usually as only a small proportion of his or her practice, the greater challenges are often the “softer,” less black or white, matters that have minimal to no evidence base, vary with cultural shifts, and truly are matters of experience and personal and professional judgment. Other challenges arise simply because of the reality that child patients are not of majority age. Consequently, completing assessments, obtaining all necessary information, and communicating with the numerous stakeholders in each case—2 or more parent figures, grandparents, teachers, therapists, probation officers, primary care physicians, and county workers, for instance—takes time and can be messy. Referral sources, treatment collaborators and systems, even the implementation and goals of psychotherapy, are different when treating minors rather than adults. Ethical and cultural considerations may also be more complicated. The rest of this article is devoted to considering work across disciplines with nonmedical professionals who provide mental health services for adolescents, and, exploring cultural, ethical, and regulatory concerns involved in antidepressant treatment of youth.

Who Refers Depressed Children and Adolescents to General Psychiatrists and Collaborates in Continued Care?

General psychiatrists typically see depressed children and adolescents in consultation for diagnosis, for second opinion or consultation regarding a diagnosis of depression, and for ongoing psychotropic medication management of depression while the young person is in ongoing psychotherapy or behavioral management with a nonphysician mental health clinician. In many ways, this mirrors the roles of child and adolescent psychiatrists who treat children in many practice settings, especially in underserved community, institutional, and forensic settings. Psychiatrists often are only at a given site 1 or more half days a week, have clinics for different types of patients and purposes, and are viewed by systems of care as highly specialized resources whose education and talents are best used tending to tasks few others can do—primarily the prescription of psychotropic medication. Often, however, medication management appointments leave little time to get to know a child or adolescent, his or her relative strengths and weaknesses, issues in the family, and concerns being addressed by therapists and case workers. More so than in general psychiatric work with adults, those who treat children must rely on the skills and conscientiousness of these other clinicians, many of whom are recruited and hired by institutions and systems of care without the input of the psychiatrist. Who are these nonphysician mental health workers who first meet our child patients, identify key issues, interface with the important others in a child's life, and implement the bulk of nonbiological treatments?


Psychologists are a varied group of professionals who study and practice psychological and educational assessments, psychotherapies, behavioral management, parent training, and research. They serve in private practices, community mental health centers, hospitals, schools, residential centers, outpatient settings, residential treatment facilities, and county agencies. They may have master's degrees or doctoral degrees, including PhD's or Doctor of Psychology (PsyD) degrees. Licensure is granted by states and often includes internships and residencies approved by accrediting bodies and required hours of patient contact and supervision. The American Psychological Association is the psychology's primary professional guild. With 154,000 members, it represents psychology in the United States and is the largest association of psychologists worldwide. It is comprised of divisions of specialties within the field, including school psychology, psychotherapy, intellectual and developmental disabilities, the Society of Clinical Child and Adolescent Psychology, and Society of Pediatric Psychology, which focuses on health behaviors. Nationwide, psychologists comprise one of the largest groups of professionals that refer children and adolescents to general psychiatrists for medication assessment and management.36

Social Workers

Social workers are another group of professionals heavily involved in the care of youth referred to general psychiatrists. Also licensed by the states, with minimum education, supervision, and continuing education requirements, social workers commonly have master's degrees, though increasingly, leadership and academics will have a PhD or Doctor of Social Work (DSW) degree. Social workers have diverse job descriptions, including individual psychotherapy, abuse work, patient advocacy, and interfacing with services in the community needed by youth and their families. They work in hospitals, community mental health centers, private practices, medical offices, county offices, and agencies. Social workers are represented, among other organizations, by the 145,000-member National Association of Social Workers, headquartered in Washington, DC. The mission of the National Association of Social Workers is to “enhance professional growth of its members, to create and maintain professional standards, and to advance sound social policy.”37

Marriage and Family Therapists

Another group of mental health professionals who work with psychiatrists, especially in areas with child psychiatrist shortages, are marriage and family therapists. This is a more diverse group of individuals, consisting of psychologists, social workers, nurses, educators, pastoral counselors, and others who identify themselves based on the patient or client population and services they provide instead of their discipline of origin. Certification is state regulated, though with more variability than other fields. Two years of clinical supervision is customarily required, and the American Association for Marriage and Family Therapy also conducts a national examination.38

Pastoral Counselors

Finally, pastoral counselors, pastoral psychotherapists, and clergy comprise a large, but diverse, group of mental health care collaborators for the general psychiatrist. Education and formal training varies greatly, ranging from no formal psychological training to second-career clergy who may have been mental health professionals earlier during their working lives. Religious professionals may counsel individuals in their congregation as part of their pastoral responsibilities, or work in churches or synagogues, private practices, or larger pastoral care centers as full-time therapists. Pastoral counselors vary with regard to how much religious and spiritual content they introduce or encourage their clients to discuss in sessions. The most reputable professional association for pastoral counselors is the American Association of Pastoral Counselors. Professional certification by American Association of Pastoral Counselors requires a 3-year professional seminary degree, a master's or doctoral degree in a mental health field, approximately 1400 hours of supervised clinical experience with 250 hours of direct supervision by approved supervisors. Religious professionals and parish clergy may provide much of the nonmedical mental health assessments and care in the very same geographical areas in which general psychiatrists may see higher proportions of adolescent patients because of shortages of child and adolescent psychiatrists.39, 40

Schools and the General Psychiatrist

All psychiatrists who care for children and adolescents must have an up-to-date familiarity with public and private primary and secondary schools in their practice locations. General psychiatrists often treat adolescents with mood and psychotic disorders who are still in high schools and may be struggling academically and socially.

The school setting has much to offer regarding adolescent mental health. School convenes daily, and, because everyone is required to go, is often a less stigmatizing location to receive care. Schools and their communities are committed to promoting qualities that enhance academic achievement, such as proper identification and treatment of psychiatric illness. They are also committed to minimizing risky behaviors that often accompany or predispose to behavioral health concerns, such as substance abuse, antisocial behaviors, and unhealthy sexual activity.41 Mental health care in the school setting can improve access for minorities, help reduce the stigma of requesting and obtaining care, and facilitate service delivery in areas that otherwise have few treatment options.42, 43, 44 Service provision in school may lead to improved attendance and fewer behavioral concerns.45 In addition, adults serving youth in school settings typically are educated, have devoted their professional lives to education, and are invested in the total well-being of their students. School professionals, therefore, are valuable collaborators, multidisciplinary team members, and even rich patient referral sources for general psychiatrists who offer pharmacotherapy to adolescents. And, even in the current age of geographical mobility, schools know countless families over many years, provide continuity for the adolescent, and are valuable sources of longitudinal information and observation for treating clinicians.

General psychiatrists who care for children and adolescents will be remiss not to be in touch with schools, if only to confirm the history provided to them by child and parents. Regular contact is often a necessity for monitoring the course and treatment of the illness. Depressed youth may be in regular or special education classes. The teachers in both settings are rich sources of historical information for diagnosis and following treatment. Many schools now have school psychologists. Their jobs may include individual and group therapy, psychological or achievement testing, running social skills groups, and developing individualized education plans (IEPs) in collaboration with school-based colleagues. In many school settings, guidance counselors see students individually in addition to their instructional advising duties. Some larger schools may have a full-time nurse, whereas smaller or financially struggling districts may assign nurses to multiple sites. In addition, depending on initial diagnosis, some patients may be working with occupational, physical, and speech and language therapists provided through the schools.

Ongoing interactions of the general psychiatrist and schools can take one of several forms or models. The physician may prescribe antidepressant medication only, and only be available to the school as an emergency contact on registration forms. Psychiatrists may prescribe for children receiving their psychotherapy from a school psychologist or guidance counselor. The physician may have a contract or arrangement with the school district whereby the psychiatrist, with parental consent, evaluates and prescribes psychotropic medication at the school. Another possible arrangement is one in which the psychiatrist consults to the school about systems and programmatic issues, instead of providing services for the individual child. This is perhaps more fitting for and commonly done by child and adolescent than general psychiatrists, although not always the case in rural, underserved areas, in which adult psychiatrists provide this service out of necessity. General psychiatrists are also in the ranks of many who offer their time for screening, assessment, and emergency care of students in crisis situations, such as student or teacher deaths, incidents of violence, or natural disasters.

General psychiatrists must be familiar with a few basic terms and statutes fundamental to education if they treat adolescents on a regular basis. The Americans with Disabilities Act, passed in 1990 and amended in 2008, states that students with disabilities cannot be denied educational services or be discriminated against after they are enrolled. Accommodations are changes in the learning or school environment to assist the student in overcoming the particular disability. Common examples for adolescent patients include providing a classroom aide for an autistic individual or personalized organization of the desk or work space area to remove distractors and enhance attention and concentration for a teen with severe attention deficit hyperactivity disorder. Accommodations often are agreed to formally in a 504 Plan, from Section 504 of the Rehabilitation Act of 1973. The Education for All Handicapped Children Act, or Public Law 94-142, now revised as the Individual with Disabilities Education Act (IDEA) includes children and adolescents with severe psychiatric and physical illnesses and handicaps. The IDEA guarantees these individuals a free public education with special instruction and services required to meet their educational needs up to the age of 22 years. The IDEA guarantees an IEP, which parents can attend and provide their input and consent. Should the parent or guardian disagree with their child's IEP or educational placement, they are afforded due process and appeal.41, 46

Identical to communication with all outside sources, the general psychiatrist must obtain consent from the patient's parent or guardian before communicating with the school. Many severely ill adolescents and young adults between the ages of 18 and 22 years may be enrolled in special education programs, and the clinician will need to establish whether the parent obtained guardianship after the young person's 18th birthday so that proper consent for communication is obtained. Even if the patient cannot give consent, obtaining their assent or agreement for the psychiatrist to speak and cooperate with the school is very important in maintaining and strengthening the therapeutic relationship between the psychiatrist and the young adult patient. As youth approach their late teens and beyond, the school setting remains just as important as their family life. Strong partnerships with their patients' educational institutions are essential for general psychiatrists who prescribe for children and adolescents, regardless of the psychiatric diagnosis.

Child and Adolescent Depression and Common Psychotherapies

As noted previously, the role of many general psychiatrists in the treatment of pediatric depression is the assessment for and ongoing management of antidepressant medication. They will be collaborating with a host of other mental health professionals who provide psychotherapy, behavioral, and case management. For optimal treatment of depression, it is imperative that the physician in these collaborative treatment arrangements understand the essentials of psychotherapies commonly used in the field, particularly as they pertain to adolescents. Four individual therapies commonly used by mental health professionals from other disciplines are reviewed: individual psychodynamic, cognitive-behavioral, interpersonal, and psychoeducation.

Individual Psychodynamic Psychotherapy

Practically speaking, individual psychotherapy often is used as an umbrella term to encompass supportive psychotherapy, brief psychotherapy, and insight-oriented, psychodynamic psychotherapy. In addition, clinicians in different disciplines describe their psychotherapeutic orientations and techniques in many ways. Therefore, it is important for the psychiatrist collaborating with a therapist to understand as completely as possible what is occurring under the rubric of individual psychotherapy.

The use of individual psychodynamic psychotherapy in children and adolescents is bolstered by a long and rich case-based literature and a wealth of clinical experience. A major advantage is that the focus, content, and, to a certain extent, the therapeutic techniques can be flexible to address developmental, family, peer, academic, and other concerns. These therapies are compatible with medication management and can also allow for therapeutic attention to more existential, less quantifiable concerns, such as the meaning of life and issues of the adolescent's emerging worldview. However, evidence-based support, although emerging and promising, is still rather limited.30, 47 Costs, time commitment, and therapist availability may limit access and use by youth and families struggling with the recent socioeconomic downturn and multiple obligations at home and work. However, psychiatrists will recognize the use of psychodynamic psychotherapy principles in even brief interventions by therapists of all backgrounds and across the continuum of outpatient care.

Cognitive–Behavioral Therapy

Cognitive–behavioral therapy (CBT), based on Beck's depression paradigms and psychotherapy techniques, long has been accepted as efficacious in the treatment of depressed adults, adolescents, and children.48, 49, 50, 51 CBT acknowledges the biopsychosocial contributors to depression, including genetics, temperament, and family environment, then addresses cognitive distortions and vulnerabilities and negative and automatic thoughts. Interventions include mood monitoring, goal setting, activity scheduling, problem solving, parent training, attention to social skills, and relapse prevention.

As psychotherapies for depressed youth go, CBT is the most studied, with numerous clinical trials, protocols, and meta-analyses of studies to support its superiority over other nonpharmacologic interventions.48, 50, 51, 52, 53, 54 CBT gained large-scale national endorsements, especially after black box warnings regarding increased suicidality were issued for antidepressants.55 However, the Treatment for Adolescents with Depression Study (TADS) called into question the infallibility of CBT in the treatment of some youths at certain points in the course of their depressive disorders. TADS was a multicenter, randomized, controlled trial of 439 adolescents, ages 12 to 17 years, with major depressive disorder. Study subjects were randomly placed into the following arms: fluoxetine, CBT, combined fluoxetine and CBT, and placebo. For the first 12 weeks of treatment, fluoxetine alone and the combination of fluoxetine and CBT were more effective than placebo, but CBT alone was not. Interestingly, at the 18-week mark of the study, the CBT-only arm showed similar improvements to the fluoxetine-alone or combined fluoxetine and CBT groups. Several publications detail additional important findings from the TADS study group.56, 57, 58, 59 TADS did not show that CBT was ineffective or unhelpful in the treatment of adolescent depression, as has been misunderstood by some when the initial 12-week data were presented. However, it may be that CBT is more effective when administered at various points in treatment, its benefits may be appreciated at different points in the course of the illness and its treatment, and certain adolescents will benefit to different degrees than others from CBT alone.

Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT) was developed as a brief, time-limited therapy for adult outpatients with unipolar, nonpsychotic depression. It is based on the straightforward observation that when one is depressed, interpersonal relationships are affected, and conversely, the quality of one's interpersonal relationships affect one's mood. General goals of IPT are to decrease depressive symptoms and improve the functioning of the depressed individual within important relationships with others. IPT for depressed adolescents (IPT-A) is a manualized, evidence-based psychotherapy that capitalizes on the importance of interpersonal relationships as a developmental cornerstone of typical adolescence. IPT-A is well suited to address common adolescent issues, such as separation/individuation from parents, peer pressure, facing deaths of relatives or friends, and developing dyadic relationships. Gunlicks-Stoessel and colleagues60 and Mufson and colleagues61, 62, 63, 64 conducted randomized, controlled trials and published extensively on IPT-A. This 12-session program has been used with depressed adolescents in clinical and school settings, with demonstrated maintenance of symptom improvement and social functioning at 1-year follow-up visits. IPT-A is compatible with antidepressant treatment and includes adaptations for use with depressed prepubertal children; pregnant teens; youths with self-injurious, nonsuicidal behaviors; and in group settings.60, 61, 62, 63, 64


Although many clinicians consider psychoeducation to be any information about a psychiatric disorder and its treatment that is conveyed to a patient or family member, the term properly refers to a more formal, standardized curriculum and procedures, typically in manualized form. It stresses education about the disorder, problem solving, and communication skills vital to symptom recognition, management, and appropriate service use. This modality uses principles from CBT, social support, client-centered, and learning theories, among others. It is used most effectively as an adjunctive treatment with pharmacotherapy. Psychoeducation with depressed adolescents and their families has demonstrated changes in dysfunctional understandings about depression and improvement in social functioning and parent–child relationships.65, 66, 67, 68

Prescribing for Children and Adolescents: The Psychodynamics of Psychopharmacology

The act of writing a prescription for a psychotropic medication for a child or adolescent is more than pen meeting a small piece of specially treated paper or printing out a form from the electronic medical record. The child or adolescent patient, parents, siblings, and extended family members, peers, teachers, and significant others may ascribe particular meanings to the circumstances culminating in the act of prescribing an antidepressant. Is the core depressive illness the result of wrongdoing, inadequacy, weakness, or sin on the part of the child or the parent? Is there an understanding of illness as multifactorial, including genetics, medical contribution, and psychosocial factors that contribute to the particular timing, expression, and severity of the patient's presentation? Was the parent neglectful in any way, in the past or the present, perhaps not seeking timely and appropriate assessment for earlier symptom expressions of the mood disorder? Do the youth and his illness remind a mother of another prominent person in her past, such as the child's abusive father? Are the parents resistant to having their teenager on an antidepressant because of embarrassment about not being able to pay for it or the difficulties they anticipate in committing to appropriate follow-up visits? The meanings ascribed to medications have the potential to determine how it is used (or not) and whether the medication helps or hurts, as discussed by Mintz in this issue.

Although most commonly associated with traditional forms of family therapy, the term identified patient remains a potentially helpful concept for clinicians prescribing medications for children and adolescents. According to Minuchin, the identified patient is the member of the family or system first put forth as the problem or the focus of the turmoil. Therapeutic intervention is expected to be directed at that individual, with the expectation that the therapist will change him or her and the troubling symptoms or behaviors. The therapist, on the other hand, views the entire family or system as symptomatic, and seeks to reverse or affect change in ineffective transactions and dysfunctional patterns of behaving within the entire family system that produce heightened affect and potential scapegoating. In essence, the identified patient can be understood as the symptom bearer for unhealthy individual, dyadic, and multiple-person interactions within the family context.69, 70 Although contemporary family therapies have become more evidence based and use practice standards and integrative treatment strategies with individual, school, and community collaborations and interventions, the identified patient concept remains helpful—even for those clinicians who prescribe medications but do not provide individual or family psychotherapeutic treatments.71, 72, 73, 74, 75, 76, 77

When deciding on antidepressant medication, the prescribing clinician must be sure she is diagnosing and treating true symptoms of the youth and not those projected on them as the family's symptom bearer. In addition to biological diatheses to affective changes, irritability, anger, and other emotions, family functioning may play a prominent part in the origin of the child's symptoms. This should always be suspected if medication responses are poor or incomplete, in addition to the pharmacologic concerns regarding drug selection, dosing, side effects, possible need for augmentation, and related questions all prescribers must always keep in mind.

Even when assessment, diagnosis, and pharmacologic treatment are performed carefully and competently by physicians, children and adolescents who are the identified patients in tumultuous family settings may still hear messages implicitly or overtly that they must take medicine because they are bad or others cannot deal with them. In some family systems, even expression of what may be a normal range of affect and emotion may be reported to doctors as pronounced symptoms of mood disorders. Youth who have been the symptom bearers for their families of origin may benefit from individual psychotherapy as young adults to process and reframe their experience of what it meant to be the identified patient and the benefits, burdens, and meanings of being prescribed psychotropic medication in that context (David L. Mintz, MD, Stockbridge, MA, personal communication, October 2011). When prescribing physicians suspect unhealthy family dynamics, and the child's family is not already in active treatment, appropriate referrals to qualified therapists should be offered.

Psychiatrists must not overlook the meaning of the physical attributes of the medication itself. Children may attribute meanings to the color, size, shape, letters, and form of medicine, whether a tablet that must be swallowed whole, an under-the-tongue meltaway, liquid, or intramuscular form. A larger pill or a frequent dosing schedule can be misperceived as meaning the child is “sicker” than if only taking a small tablet every morning, or some may be relieved that taking a larger pill several times daily is greater help or a better treatment. The adolescent's relationship with and regard for the prescribing clinician can influence her enthusiasm about adhering to medication instructions. Although children and teens typically do not need to take antidepressants during the school day, extracurricular activities, evening jobs, leisure activities, and stigma from peers can discourage reliable medication adherence in the evening or at bedtime.

Adolescence is a period of burgeoning autonomy and independence. If the teen shares a therapist or a psychiatrist with family members or others they know through school, extracurricular activities, or employment settings, he may express his individuality by refusing to attend the appointment, have the prescription filled, or taking the medication at all. It is always wise to inquire about these potential conflicts before or during the assessment of an adolescent, and certainly before contemplating prescribing an antidepressant. If this appears to be an issue that may interfere with treatment, referring to a different psychiatrist for pharmacotherapy should be considered to hasten symptom remediation. As noted previously, in many rural and inner city areas there is a shortage of child psychiatrists, and available general psychiatrists may choose not to prescribe for individuals less than 18 years of age. In situations in which treatment by another psychiatrist is not possible, perhaps because of clinician shortage or restrictive provider lists of third-party payers, the trust and confidentiality concerns inherent to an adolescent and another family member being cared for by the same psychopharmacologist should be discussed openly with all concerned before writing the first prescription.

In addition to developmental and family considerations, general psychiatrists treating depressed children and adolescents should keep in mind the ever-increasing cultural and religious plurality of the communities in which they practice. Clinicians should inquire in greater detail about these issues whenever the psychodynamics, treatment adherence, or the relationships of prescriber, minor patient, and parent or guardian require further reflection.77, 78, 79

Ethical Aspects of Child and Adolescent Pharmacotherapy Basic Ethical Principles

Several reviews exist regarding basic ethical principles in child and adolescent psychiatry clinical practice and research.80, 81, 82, 83 In general, the application of the principles of beneficence and nonmaleficence are quite similar in prescribing psychotropic medications for children, adolescents, and adults. All clinicians are obligated to seek out and to provide the best possible care for their patients (beneficence), and in so doing, fulfill the duty or moral obligation to avoid harm. Indeed, the physician's cardinal rule is “primum non nocere,” or “do no harm.” No psychotropic medications, including antidepressants, have so few risks to be considered beneficial in all situations. Even when using medications with relatively few side effects compared with other agents in the treatment of pediatric depression, prescribers must weigh the potential risks with the potential harms of medication side effects, potential drug interactions, and deleterious effects on growth and development.84, 85, 86

Justice has taken on much greater significance in recent years as the prescription of psychotropic medications to children and adolescents has come under greater scrutiny. In the discipline of philosophy, justice signifies fairness, or similar regard or treatment of individuals in comparable circumstances. In psychiatry and pediatrics, the term justice often is used to signify the narrower concept of distributive justice, or the fair distribution and access to care and treatment as determined by the norms, policies, and procedures of society and its processes for determining these guidelines.84, 87 Perhaps no other medical specialty faces issues of distributive justice more so than child and adolescent psychiatry. Psychiatrically ill youth are one of the largest marginalized groups in health care, and justice issues and inadequate access to services contribute to the rates of depression, recurrence, and suicide. In addition, fairness and distributive justice, or lack thereof, are key considerations in the economics and business of health care and pharmaceuticals, all of which affect the type, amount, and quality of antidepressants on insurance and third-party payer formularies available to treat depression and other psychiatric illnesses in children.88, 89, 90, 91, 92

Over the last decade, data about psychotropic medication prescription practices in the United States has provided food for thought regarding justice and mental health care for youth. The overall rate of psychotropic medication use increased from 1.4 per 100 children in 1987 to 3.9 per 100 children in 1996. These figures reflected increases not only for antidepressants but for all medications except benzodiazepines and antipsychotics.93 Looking specifically at antidepressants, prescription rates for selective serotonin reuptake inhibitors increased until 2000, whereas those for tricyclic antidepressants decreased. In 2002, an estimated 0.3% to 0.9% of adolescents were prescribed a selective serotonin reuptake inhibitor, and prescription rates were higher for whites than Hispanics but comparable in boys and girls.94, 95

Other researchers have examined sex and racial patterns for psychotropic prescription in children and adolescents. One study of Medicaid databases in 7 states found that 2.3% of preschoolers received 1 or more prescriptions in 2001, double the rate calculated for 1995. Boys were twice as likely to receive prescriptions as girls, whites 2 times more likely than African Americans and 4 times more likely than Hispanics. In this particular Medicaid preschooler study, atypical antipsychotics and antidepressants accounted for the most significant increases in prescriptions.92 In general, studies in all practice settings consistently report that boys are 2 to 4 times as likely as girls to receive a psychotropic medication.96, 97 Although this difference may be attributed at least in part to the epidemiology of certain entities, with some Axis I disorders, such as attention deficit hyperactivity disorder, known to be more common in boys than girls, epidemiologic arguments do not explain other ethnic disparities. Data also are emerging on psychotropic prescription rates for vulnerable children, such as those in foster care. Zito and coworkers98 discovered that children in foster care insured by Medicaid received significantly more prescriptions than children matched for age and sex who were also covered by Medicaid but not in foster care. Forty-three percent of the foster care children received prescriptions for 3 or more classes of agents during 2004 alone. Antidepressants were the most commonly prescribed medications, with psychostimulants and antipsychotics prescribed somewhat less often.98

Although no single, clear-cut, evidence-based explanation exists for the degree of unevenness of care across socioeconomic and cultural groups, from a philosophical point of view, this issue can be conceptualized at the following levels: (1) the pediatric patient and his or her family, (2) the individual practitioner in any given clinical encounter, (3) organized medicine, medical education, and systems of care as elements of the larger US health care system, and (4) the values and priorities of American society in general. For instance, are there particular ways in which pediatric depression presents or the symptoms are expressed or reported in nonmajority populations that predispose them to receive prescriptions for medications at a higher rate than other children? Are there language and cultural barriers that limit recommendations for and acceptance of nonpharmacologic treatments modalities? Are there significant differences in training, experience, and supervision of physicians prescribing for minority youth? Are there common elements or characteristics of these clinicians that, when compared with clinicians treating majority youth, distinguish their practice and prescribing patterns, potentially contributing to different psychopharmacologic treatments for different groups of patients? The medical community as a whole may be a factor in discrepant rates of prescription in different patient groups.

Efforts to improve access to high-quality care to underserved patient populations, to increase the number of child and adolescent psychiatrists nationally, and to supplement training and expertise of primary care physicians and general psychiatrists in the area of pediatric psychopharmacology are certainly underway. Although data on these initiatives are not yet available, one would like to be optimistic that these efforts will improve access to higher-quality care for all pediatric mental health concerns.

At a societal level, for just and equitable care for depressed children and adolescents to become the rule for all youth, the issue must not only be kept in the forefront of public awareness but also at the top of the “to do” or “must have” lists of voting citizens, school boards, and government at all levels—local, state, and federal. If justice in the area of care for childhood and adolescent depression means reasonable access for all children and families to quality of care supported by evidence-based practices, all must make the need known and insist on its availability—patients, families, clinicians, schools, professional guilds, and societal groups advocating and determining policies for health care access and systems of care.

Certainly, more work needs to be done in epidemiology of psychiatric disorders, standardization of accurate diagnostic methods and tools, and service delivery and economics to increase mental health care and access to appropriately prescribed psychotropics to those youth who need them. More work also needs to be done to decrease unnecessary or inappropriate prescriptions to those who do not need or are unlikely to benefit.

Informed Consent and Assent

According to expert ethicists, informed consent consists of 5 elements: (1) competence, (2) disclosure, (3) understanding, (4) voluntariness, and (5) consent.99 Building on the work of Appelbaum and coworkers,100 the American Academy of Pediatrics enumerated the following elements of informed consent:

  • 1 “Provision of information: Patients should have explanations, in understandable language, of the nature of the ailment and condition; the nature of proposed diagnostic steps and/or treatment(s) and the probability of their success; the existence and nature of risks involved; and the existence, potential benefits, and risks of recommended alternative treatments (including the choice of no treatment).”

  • 2 Assessment of the patient's understanding of the above information.

  • 3 Assessment, if only tacit, of the capacity of the patient or surrogate to make the necessary decision(s).

  • 4 “Assurance, insofar as is possible, that the patient has the freedom to choose among the medical alternatives without coercion or manipulation.”101

In the majority of cases, parents and guardians provide informed consent for depressed minors to be treated for their illness and to receive antidepressant medications. Children who are in foster care, incarcerated, or for other reasons wards of the county or state have their consent for care given by an authorized person(s) of the custodial entity, sometimes with input from a parent or other family member. The consent process may be complicated and lengthy when multiple adults and agencies are involved. Regardless of who gives legal consent—parent, guardian, or other designated authority—several compelling reasons exist for obtaining assent, or agreement, on the part of the identified child patient when psychotropic medication is recommended.85 The American Academy of Pediatrics has named 4 essential components of assent, all very relevant to antidepressant treatment for youth:

  • 1 “Helping the patient achieve a developmentally appropriate awareness of the nature of his or her condition”

  • 2 Telling the patient what he or she can expect with test(s) and treatment(s)

  • 3 Making a clinical assessment of the patient's understanding of the situation and the factors influencing how he or she is responding (including whether there is inappropriate pressure to accept testing or therapy)

  • 4 “Soliciting an expression of the patient's willingness to accept the proposed care.”101

If the child or adolescent does not assent to the treatment, or if there is extreme reluctance to give assent, the prescribing psychiatrist should take the time to understand the patient's concerns and work through them patiently with her. Often, an impasse can be worked through given additional time and developmentally appropriate education about the mood disorder, its treatments, and the benefits of treatment.

From time to time, the general psychiatrist will treat an individual younger than 18 years who can legally consent to treatment, including pharmacotherapy. The term emancipated minor applies to individuals less than 18 years of age who are in the armed services, married, are parents themselves or who are living outside the home of their family of origin and are in charge of their own finances and affairs. Exact criteria for the status of emancipation vary across jurisdictions, so clinicians should consult local or state officials for guidance when initially treating these young people.85

Reviewing written information about childhood and adolescent depression and antidepressant medication with the parent and youth at the time of obtaining informed consent and assent can strengthen therapeutic relationships, provide visual input in addition to the listening element of consent/assent, and permit review and reflection on the same material after they leave the office or hospital setting. Several easily understood references for parents and developmentally appropriate information sheets for children and adolescents are available, authored and furnished by reputable clinicians and professional organizations.102, 103, 104

Black Box Warnings and Off-Label Prescribing

Black box warnings refer to warnings placed by the US Food and Drug Administration (FDA) regarding important concerns about the safety of medications. The concerns may relate to particular characteristics of the patient population involved, the condition(s) being treated, or serious or life-threatening side effects, either short or long term. Over the last decade, several medications in multiple drug classes commonly prescribed to treat child and adolescent psychiatric disorders have been given black box warning status.

In 2003, a possible association between paroxetine and suicidal ideation was noted in controlled trials in child and adolescent populations.105 Based on this concern, the FDA asked all manufacturers of antidepressants to resubmit safety data from controlled trials in pediatric populations. In a meta-analysis of the safety data from 24 pediatric antidepressant trials, a 4% risk of suicidality was demonstrated by youth on active medication compared with a 2% risk of the same in patients on placebo. In 2004, based on this meta-analysis, the FDA issued a black box warning for all antidepressant use in children and adolescents, regardless of the disorder for which they were actually prescribed. In addition, guidelines were issued recommending patient monitoring consisting of weekly face-to-face visits with the clinician for 4 weeks, followed by biweekly meetings for the next 4-week period, and then monthly appointments.106 The effect of the 2004 black box warning was a significant decrease in the prescription of antidepressants to children and adolescents.107 A subsequent meta-analysis of data from approximately 77,000 subjects in 295 placebo-controlled trials found similar increased risk of suicidality in young adults up to the age of 24 years. As a result, the black box warning for antidepressants was extended to 24-year-olds in December 2006.108 As might be predicted, both the rates of depression diagnosis and the prescription of antidepressants have declined since the requirement for black box warnings for antidepressant therapy for patients under the age of 25 years.109, 110, 111 As some opponents of the black box warnings feared, the decrease in antidepressant prescriptions has been correlated to an increase in completed suicides in this population in the years immediately after the issuance of these black box warnings.112

Off-label prescribing refers to using a drug to treat an illness or condition or a particular patient population for which the drug is not approved by the FDA. Just because a medication has been approved for use in one patient population for a specific disorder does not mean that it is effective or safe to use in the same or comparable condition in a different population.113 This is often the case in the treatment of childhood depression. Fluoxetine has an FDA approval for the treatment of major depressive disorder in children 8 years and older, and escitalopram has an FDA approval for the treatment of depression in youth 12 years and older. With those 2 exceptions, use of all other pharmacologic agents to treat depressed pediatric patients is indeed off-label. Clinicians must use their medical fund of knowledge, clinical experience, and wisdom to weigh the risks and benefits of treatment and which specific antidepressant to prescribe. Parents and caregivers should be informed if the recommended treatment is FDA approved or off label, as well as the reasons the physician is recommending the particular medication being prescribed.22 The passage of key federal legislation, including that US Food and Drug Administration Modernization Act of 1997, the Best Pharmaceuticals for Children Act in 2002, and the Pediatric Research Equality Act of 2003, has required and encouraged multicenter trials of psychotropic medications in pediatric patient populations. National Institutes of Health initiatives have also incentivized more scientifically rigorous research in pediatric psychopharmacology. Information and experience gleaned from these multicenter studies should enlighten prescribers on both the benefits and risks of antidepressants, give greater direction about which medications to try, in particular, contexts with certain individual patients, and be helpful to prescribers and parents as we all attempt to act in the child's best interests.114

Kratochvil has offered a clinically and ethically reasonable approach to the issue of youth and young adult depression, antidepressant prescription, and the black box warnings. He stated that astute informed clinicians will know how to interpret relevant data about risks and benefits of a treatment, even if information is still coming forward. The clinician will share with patients and families the benefits and risks of potential treatments, of not treating, and what and how monitoring for treatment effects should be accomplished. Treatment with antidepressants may require flexibility on the prescriber's part, perhaps even first trying alternatives to the physician's first recommendation. Regardless, close monitoring of the patient's condition is essential.77


Depression is a common, recurring disorder affecting millions of youth at some point before they reach mature adulthood. Given the shortage of and uneven distribution of psychiatrists who have completed specialized fellowships in child and adolescent psychiatry, a significant number of depressed youth will receive their pharmacotherapy from general psychiatrists and other prescribers with varying degrees of interest, training, and even willingness to treat children and adolescents. For general psychiatrists who will prescribe antidepressants for minors, knowledge of the training and expertise of nonphysician mental health professionals, the psychotherapies they may employ, and familiarity with school services are essential. Physicians who typically work only with adults will also need familiarity with differing ethical, legal, and regulatory issues and standards applicable to pediatric psychopharmacology. General psychiatrists, pediatricians, family physicians, nurse practitioners, and others contribute greatly to the care of depressed children, adolescents, and their families, and many find this work to be a very rewarding part of their professional practices.


The author gratefully acknowledges the assistance of Jennifer Staley, MLIS, librarian at the Pediatrics Learning Center at Rainbow Babies and Children's Hospital.

The author has nothing to disclose.

Case Western Reserve University School of Medicine, 10524 Euclid Avenue, W.O. Walker Building, Suite 1155A, Cleveland, OH 44106 mary.dell@UHhospitals.org


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