Use of Medication in Treating Childhood and Adolescent Depression:
Information for Physicians
American Psychiatric Association (APA) and
American Academy of Child and Adolescent Psychiatry (AACAP)
In consultation with
A National Coalition of Concerned Parents, Providers, and
October 15, 2004, the Food and Drug Administration directed pharmaceutical
companies to label all antidepressant medications distributed in
the U.S. with a black box warning that the medications "..increase
the risk of suicidal thinking and behavior (suicidality) in children
and adolescents with major depressive disorder (MDD) or other psychiatric
disorders."1 The warning states
that the increased risk of suicidal thinking and/or behavior in
a small proportion of children and adolescents is most likely to
occur during the early phases of treatment. The FDA did not prohibit
use of the medications in youth, but called on physicians and parents
to closely monitor children and adolescents who are taking antidepressants
for a worsening in symptoms of depression or unusual changes in
American Psychiatric Association (APA) and the American Academy
of Child and Adolescent Psychiatry (AACAP) represent the majority
of the Nation’s general psychiatrists and child and adolescent
psychiatrists. The APA and AACAP share the concern that the FDA
action may limit access to necessary, appropriate, and effective
treatment for children and adolescents with depression, anxiety,
and other psychiatric disorders.
competing issues emerged in the deliberations of the FDA advisory
panel: A) a belief that the need for close monitoring of suicidal
thoughts and behaviors among child and adolescent patients receiving
antidepressant medications is essential and would be underscored
by a black box warning, and B) awareness of the risk that a black
box would have the unintended effect of limiting access to necessary,
appropriate, and effective treatment. The APA and AACAP are concerned
that the scientifically proven benefits of treating depression with
antidepressants may be under-emphasized or even disregarded in current
discussions of the potential risks of these medications.
with psychiatrists, pediatricians and other primary care physicians
play a critical role in the provision of medical care for children
and adolescents with depression and related disorders. Yet many
physicians are finding that the black box warning is fostering fear
and concern in families in which a child or adolescent is currently
receiving appropriate and effective medical treatment, including
medication, for depression. Such concerns have been intensified
by contradictory and often confusing media reports about the purported
risks that antidepressant medications pose to young patients.
medications are and will continue to be an important and valuable
component of comprehensive treatment of pediatric mental disorders.
For this reason, the APA and AACAP collaborated in preparing this
Fact Sheet to provide physicians with accurate information on the
appropriate use of these medications, as a component of a comprehensive
treatment program for child and adolescent patients.
and impact of child/adolescent depression
and suicide are national public health problems for children and
adolescents. Major depression affects an estimated 2.5% of children
and 8.3% of U.S. adolescents. These rates account for approximately
2.6 million youth ages 6 - 17.2
depression can affect every facet of a young person’s life:
family and peer relationships, academic performance, and general
health through the effects of depression on concentration, eating,
sleeping, and exercise patterns. Depression tends to be an episodic,
recurrent illness. It frequently is associated with disabling anxiety
and with thoughts of suicide experienced by 40- to 80% of youth
with the illness3, suicide attempts
by up to 35% of depressed youth4,
and, very rarely, completed suicides. Once a child or adolescent
has one period of depression, he or she is likely to get depressed
again at some point in the future5.
is a serious medical illness and may be potentially lethal because
of the risk of suicide. However, when recognized and correctly diagnosed,
it can be treated successfully, using a combination of therapeutic
approaches. These include medication, psychotherapy, or both, individualized
to the needs of a child and his or her family.
of treatment effectiveness and suicidality
effectiveness of treatment was demonstrated recently in a definitive
study supported by the National Institute of Mental Health (NIMH).
The Treatment of Adolescents with Depression Study (TADS)6
showed that a combination of fluoxetine (Prozac®) and cognitive
behavior therapy (CBT) led to significant clinical improvement in
71% of moderately to severely depressed adolescent patients. Improvement
rates for other treatment groups in the study were 61% for fluoxetine
alone, 43% for CBT alone, and 35% for placebo. This finding replicated
two previous positive studies in pediatric populations7
finding of the TADS concerned the positive impact of treatment on
suicidal thoughts and behaviors, or "suicidality," in
depressed youngsters. Suicidal ideation is a key symptom of major
depression. It is typically present before the start of antidepressant
treatment and is one of the major symptoms targeted for treatment.
Since mood disturbances often are among the last symptoms to remit
in treatment, and because antidepressant medications typically require
several weeks to exert a clinical effect, the initial changes in
brain functioning brought about by treatment are often not adequate
to suppress suicidal thoughts. In the event that worsening might
occur, the physician, in collaboration with the child’s parents
or other family members, must appreciate the importance of intensively
monitoring a pediatric patient to assure patient safety during the
early stage of treatment. In some instances, hospitalization may
be necessary, although the vast majority of patients respond to
this backdrop, it is noteworthy that in the TADS, 29% of the depressed
young patients reported having clinically significant suicidal thoughts
at baseline. At week twelve, the number of youth reporting any suicidal
ideation had declined to 10%. Because youngsters who were most suicidal
were excluded from the TADS sample, the proportion reporting suicidal
thoughts when the study began was substantially lower than rates
of suicidal ideation found in the community samples cited above
(reference #3) of youth with major depressive disorder.
appropriate treatment, the consequences of depression are extremely
serious. Children are likely to have ongoing problems in school,
at home, and with their friends. Four of ten will have a second
episode of depression within two years9.
They are also at increased risk for substance abuse, eating disorders,
and adolescent pregnancy10. Research
indicates that over half of depressed youth will eventually attempt
suicide, and an estimated 2- to 5% will die by suicide in the 10
to 20 years following an initial episode11.
prompted the FDA warning?
2004, the FDA reviewed 23 clinical trials involving more than 4,300
child and adolescent patients who received any of nine different
antidepressant medications12. No
suicides occurred in any of these studies. Most of the
studies that the FDA examined used two measures to assess suicidal
thinking and behavior.
All used "Adverse Event Reports," which are reports made
by the research clinician if a patient (or their parent) spontaneously
shares thoughts about suicide or describes potentially dangerous
behavior. The FDA found that such "adverse events" were
reported by approximately 4% of all children and adolescents taking
medication compared with 2% of those taking a placebo. One of the
problems with using this approach to measuring suicidal thinking
is that most teenagers do not talk about their suicidal thoughts
unless they are asked13, in which
case no report is filed.
In 17 of the 23 studies a second measure was also available. These
were standardized forms asking about suicidal thoughts and behaviors
completed for each child or teen at each visit. In the views of
many experts these measures are more reliable than event reports.
The FDA's analysis of the data from these 17 studies found
that medication neither increased suicidality that had been present
before treatment, nor did it induce new suicidality in those who
were not thinking about suicide at the start of the study. In fact,
on these measures, all studies combined showed a slight reduction
in suicidality over the course of treatment. Although the FDA reported
both sets of findings, they did not comment on the contradiction
the 2% and 4% spontaneous report rates need to be understood in
the context of findings from community samples cited previously
in which as many as half or more of teenagers with major depression
are thinking about suicide at the time of diagnosis and some 16%
to 35% have made a previous suicide attempt.
only nine medications were re-examined in the analysis, the FDA
applied the labeling changes to all antidepressant medications.
This was done on the basis of the advisory committee’s perception
that currently available data are inadequate to exclude any single
medication from being potentially associated with the same increased
risk for spontaneous reports of suicidal thinking and/or behavior
found in the 23 studies.
ideation and suicide attempts are common in adolescence and do not
have the same prognostic significance for completed suicide as those
behaviors in later life.
federal Centers for Disease Prevention and Control, or CDC, reports
that 17% of adolescents think about suicide in a given year14.
Among high school students, 12% of girls and 5% of boys attempt
suicide in a given year. Ultimately, 2 per 100,000 girls and 12
per 100,000 boys die as a result of such attempts — a ratio
of attempts to completed suicide that is 6,000 to 1 among girls
and 400 to 1 among boys. In the U.S., this translates into approximately
2000 young people who die each year as a result of suicide.
the overall rate of suicide in the 10-19 year age range has declined
by 25% over the past decade. Since this decade has been associated
with a dramatic increase in the prescription rates of the newer
SSRI antidepressants, a recent study has demonstrated that a 1%
increase in prescription of antidepressant medication was associated
with a 0.23 per 100,000 decrease in adolescent suicides15.
is important to consider clinical trial data in the context of these
population-based data. In its review of 23 clinical trials involving
child and adolescent subjects who received any of nine different
antidepressant medications, the FDA combined the rates for suicidal
thoughts and suicide attempts under the general term "suicidality."
This has fostered a public impression that there is a high rate
of suicide attempts or even completed suicides in children and adolescents
that can be attributed to taking antidepressant medication; in fact,
suicidal thoughts and actions decline with medication and psychotherapy
treatments, and there were no completed suicides in the studies
reviewed by FDA. Suicidal thoughts or attempts do not equal
suicide is a personal tragedy that may be linked to inadequate treatment
monitoring or severe adverse side-effects of a medication. Yet the
rise in overall population treatment rates with antidepressant medication
has not been associated with a rise in completed suicides in the
larger population — in fact, there has been a substantial
decrease in completed suicides over the past decade. Likewise, the
higher spontaneous reports of suicidal ideation and attempts (referred
to by the FDA as "adverse events") in children on antidepressants
compared with placebo, has not been correlated with systematic assessments
of suicidal ideation or attempts increasing with these medications.
Research is needed to determine how the relatively low rate of spontaneous
reports of adverse events is related to the much higher systematically
assessed rates of suicidal ideation and attempts, and which more
clearly indicate a risk for completed suicide.
an illness where unwanted and spontaneous suicidal thoughts are
integral symptom components, treatment that increases communication
about these symptoms can lead to more appropriate monitoring and
decreased risk for the adverse event of greatest concern —
i.e. completed suicide.
and diagnosis of childhood/adolescent depression
research has identified the signs and symptoms of major depression16.
In children, these classic symptoms often may be obscured by other
behavioral and physical complaints – features such as those
in the right column of the table below. At least five symptoms must
be present to the extent that they interfere with daily functioning
over a minimal period of two weeks.
Symptoms of Major Depressive
As Frequently Seen in Youth
mood most of the day
or cranky mood; Preoccupation with nihilistic song lyrics
interest/enjoyment in once-favorite activities
of interest in sports, video games, and activities with friends
to gain weight as normally expected; anorexia or bulimia; frequent
complaints of physical illness, e.g., headache, stomach ache
late-night TV; refusal to wake for school in the morning
of running away from home, or efforts to do so
or loss of energy
self-esteem; feelings of guilt
and/or negative behavior
ability to concentrate; indecisive
performance in school; frequent absences
suicidal ideation or behavior
suicidal ideation or behavior
diagnosis of depression or other psychiatric disorders should be
made only in the context of a complete medical examination to identify
and/or eliminate any comorbid and/or confounding psychiatric or
somatic conditions. More than half of all youth with MDD have other
psychiatric disorders, with a significant proportion having two
or more disorders17.
depression, or clinical depression, is one form of the larger group
of mood disorders. These include dysthymia, a mood disorder
in which symptoms generally are less severe than in major depression,
but the illness is marked by a more chronic and persistent course.
Another form of the illness is bipolar disorder in which
periods of depression alternate with periods of mania, the hallmarks
of which are unnaturally high levels of energy, grandiosity, and/or
irritability. Bipolar disorder may first appear as a depressed episode.
Research has shown that treating unrecognized bipolar depression
with antidepressant medications may trigger the manic phase of the
illness. Children who have a family history of bipolar disorder
will require special treatment considerations that should be addressed
in any comprehensive treatment plan.
experience suggests that depression in younger children may be a
heterogeneous disorder with multiple etiological factors. Adolescent
depression appears to demonstrate greater continuity with major
depressive disorder in adults.
factors for suicide
patients with a depressive disorder do not plan, attempt, or complete
suicide; however, an estimated 60% of people who die by suicide
have had a mood disorder; among younger patients, comorbid substance
use disorders are also common18.
behavior is complex. Some risk factors vary with age, gender and
ethnic group and may even change over time. Risk factors for suicide
frequently occur in combination. Adverse life events in combination
with other strong risk factors, such as depression may lead to suicide.
However, suicide and suicidal behavior are not normal responses
to the stresses experienced by most people. Many people experience
one or more risk factors and are not suicidal.
evidence and clinical experience are generally in concurrence that
the two key risk factors for suicide are a) the presence of one
or more diagnosable mental disorders – particularly a depressive
disorder or an aggressive/disruptive disorder – occurring
alone or comorbid with an alcohol or other drug use disorder, and
b) a prior suicide attempt.
has identified an array of more general factors associated with
suicide. These include, but are not limited to, impulsivity; a family
history of mental or substance abuse disorder; a family history
of suicide; family violence, including physical or sexual abuse;
the presence of a firearm in the home; incarceration; and exposure
to the suicidal behavior of others, including family, peers, or
in the news or fiction stories. Clinicians have found that the immediacy
of the threat posed by these general risk factors may be influenced
by the two key factors listed above, that is, the presence of mental
and/or substance abuse disorders and history of a prior suicide
is important to note, however, that none of these risk factors are
linked specifically to use of antidepressant medications by children
talking about suicide signal increased likelihood that a child will
expression of suicidal thoughts or feelings by a child or adolescent
is a clear signal of distress and should be taken very seriously
by health care professionals, parents, family members, and others.
Psychiatrists and other mental health specialists have found that
when a young person verbalizes suicidal thoughts, it often opens
the door to communication regarding the need to take special safety
precautions or protective measures; thus any therapeutic intervention
that increases discussion of latent, or hidden, suicidal thoughts
or impulses is helpful. Much more worrisome and potentially dangerous
is a young person with depression who successfully hides the fact
that he or she is having suicidal thoughts.
childhood and adolescent depression
physician, in consultation with the patient and parents/guardians,
should develop a comprehensive treatment plan. This typically will
include individual psychotherapy, medication, or combined psychotherapy
and medication, and work with the child’s family and/or school.
Several months of treatment may be necessary before depressed mood
and accompanying suicidal thoughts and feelings begin to improve.
strategies for comprehensive treatment plans for major depressive
disorder are available in AACAP’s Practice Parameter on Depressive
Disorders17 and the APA Practice Guideline on the Treatment of Patients
with Major Depressive Disorder19.
Medication alone and/or psychotherapy alone are efficacious in the
treatment of depression, but the combined treatments are the best
and, when possible, they are preferred. Moreover, not all young
people with depression need to be treated with medication. Many
children and adolescents with uncomplicated major depressive disorder
respond well to psychotherapy20
Cognitive behavioral therapy (CBT), and interpersonal therapy (IPT)
have been shown to be effective in treating milder forms of depression
as well as anxiety and OCD.
The aim of CBT is to help a patient recognize and change negative
patterns of thinking that may contribute to depression.
and other mental disorders frequently affect interpersonal relationships
and roles in those relationships. The aim of IPT is to help an
individual to address issues such as interpersonal disputes or
conflicts, role transitions, or other events that seem to be most
important in the onset and/or maintenance of depression.
seeing a skilled health professional regularly for several weeks
will result in a reduction in the symptoms of depression in about
a third of teenagers. Although this is sometimes confused with a
"placebo effect," the interest and support of a health
care professional does have a more positive impact on symptom response
than neglect or denial of the patient’s condition23.
At the initial diagnostic assessment and every subsequent clinical
encounter, the physician should ask a patient directly about the
occurrence of suicidal thoughts or behaviors in the current episode
strategies for suicide prevention should be employed if a child,
or any member of a family, has depression. Lethal means, such as
guns should be removed from the house, and large quantities of dangerous
medications, including over-the-counter medications, should not
be left in an accessible location. The physician should work with
families to develop an emergency action plan, including access to
a 24-hour number available to deal with crises.
should be advised to contact the supervising physician immediately
if a child voices new or more frequent thoughts of wanting to die
or to hurt him- or herself, or takes steps to do so.
used in combination with a medication, interventions such as CBT
may have a significant protective effect against suicidal ideation
for physicians when prescribing antidepressant medication to pediatric
the antidepressants, one – fluoxetine, or Prozac® –
is formally approved by the FDA for treating depression in pediatric
patients – based on evidence of greater effectiveness than
placebo in carefully designed clinical trials. Prozac and three
other medications – sertraline (Zoloft®), fluvoxamine,
and clomipramine (Anafranil®) – are approved for treating
obsessive-compulsive disorder (OCD) in children and youth.
prescribing of antidepressants to child and adolescent patients
is common and consistent with general clinical practice. Of the
approximately 30% to 40% of children and adolescents who do not
respond to an initial medication, a substantial number will respond
to an alternate medication.
physician should describe and discuss with parent/guardian and with
the child or adolescent patient the risks and benefits of any treatment,
including treatment with medication.
no clinical response is evident in 6-8 weeks, the physician should
reevaluate the treatment plan and consider modifications, as appropriate.
Consideration of an alternative treatment is not limited to youth
who are being treated with medication, but also to those receiving
psychotherapy or other interventions.
a child/adolescent receiving antidepressant medication
Careful monitoring by physicians and parents of children’s
mental health and behavioral status upon initiation of antidepressants
and changes in medications and/or dosages is critically important.
FDA recommends that "ideally" a child receiving antidepressants
will be seen by the prescribing physician once a week for the first
four weeks of treatment; biweekly for the second month of treatment;
and at the end of the 12th week on medication. The APA and AACAP
believe that rather than requiring adherence to a prescribed schedule,
the frequency and nature of monitoring should be individualized
to the needs of child and family.
physician should enlist parents/guardians in the responsibility
of monitoring. Family members should contact their child’s
physician if the child or adolescent patient:
new or more frequent thoughts of wanting to die, or engages in
shows signs of increased anxiety/panic, agitation, aggressiveness,
experiences involuntary restlessness (akathisia), or an extreme
degree of unwarranted elation or energy accompanied by fast, driven
speech and unrealistic plans or goals.
reactions to antidepressant medication are most likely to occur
early in the course of treatment. It may be appropriate to adjust
the dosage, change to a different medication, or stop using medication.
In a small number of instances, a child or adolescent might have
extreme reactions to antidepressants or other commonly used medications
such as penicillin or aspirin as a result of genetic, allergic,
drug interaction, or other unknown factors.
a child/adolescent pediatric patient is being treated with a medication
and is doing well, he or she should continue with the treatment.
No patient should abruptly stop taking antidepressant medications
because of the possibility of adverse withdrawal effects such as
agitation or increased depression. The physician should convey to
parents the importance of consulting with the physician before changing
or terminating their child’s antidepressant treatment.
medications will carry the warning label?
Anafranil (clomipramine HCl)
Paxil (paroxetine HCl)
Aventyl (nortriptyline HCl)
Pexeva (paroxetine mesylate)
Celexa (citalopram HBr)
Prozac (fluoxetine HCl)
Cymbalta (duloxetine HCl)
Desyrel (trazodone HCl)
Sarafem (fluoxetine HCl)
Effexor (Venlafaxine HCl)
Elavil (amitriptyline HCl)
Sinequan (doxepine HCl)
Lexapro (escitalopram oxalate)
Tofranil (imipramine HCl)
Ludiomil (Maprotiline HCl)
Tofranil-PM (imipramine pamoate)
Vivactil (protriptyline HCl)
Nardil (phenelzine sulfate)
Wellbutrin (bupropion HCl)
• Norpramin (desipramine HCl)
Zoloft (Sertraline HCl)
• Pamelor (nortriptyline HCl)
Zyban (bupropion HCl)
Parnate (tranylcypromine sulfate)
antidepressant medications under development now and in the
of depression outcome measures
American Academy of Pediatrics recommends tools such as the Beck
Depression Inventory and the Children’s Depression Inventory-Revised
for use in monitoring a child’s response to treatment. While
rating scales are not definitive for diagnosing depression, they
can help guide questions during follow-up monitoring appointments.
depression screening and severity measurement tools developed specifically
for adolescents are currently in development. The APA and AACAP
will disseminate information on these instruments as it becomes
controversy and conflicting information surrounding the prescribing
of antidepressant medications to children and adolescents has underscored
the importance of ongoing discussions regarding need for a comprehensive
national registry of clinical trials that is readily accessible
to physicians, researchers and the general public. The AACAP and
APA were at the forefront in calling for the development of such
APA and AACAP also will continue to participate in and monitor important
ongoing research that will shed additional light on questions surrounding
antidepressant medications and pediatric patients. The National
Institute of Mental Health [see http://www.nimh.nih.gov/studies/index.cfm]
is currently funding three potentially informative projects. These
the Treatment of Resistant Depression in Adolescents, or TORDIA
study, designed to determine how to best treat adolescents with
depression that is "resistant" to the first SSRI antidepressant
they have tried. Participants receive one of three other antidepressant
medications, either alone or in combination with cognitive behavioral
the Treatment of Adolescent Suicide Attempters, or TASA study,
in which participants are randomly assigned to receive carefully
monitored antidepressant medication with routine support and management,
cognitive behavioral therapy (CBT), or a combination of antidepressant
medication plus CBT.
Finally, data derived from the extended phase of the year-long
TADS – only results of the first 12 weeks have been published,
as discussed in this Fact Sheet – are being analyzed and
promise to significantly enhance our understanding of long-term
outcomes associated with the treatments under study.
APA and AACAP will update this Fact Sheet as additional information
becomes available from these sources as well as investigator-initiated
and industry-sponsored studies.
Academy of Child and Adolescent Psychiatry
Association of Suicidology
American Foundation for Suicide Prevention
American Psychiatric Association
American Society for Adolescent
Depression and Bipolar Support
Families for Depression Awareness
National Association of Psychiatric
Society for Adolescent
Suicide Awareness Voices of Education
Food and Drug Administration. FDA public health
advisory: sucidality in children and adolescents being treated
with antidepressant medications [online]. 2004 Oct 15. Available
at URL: http://www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm
[Accessed 2004 Dec 16]
Birmaher B, Ryan ND, Williamson, DE, et al (1996).
Childhood and adolescent depression: a review of the past 10 years.
Part I. J Am Acad Child Adolescent Psychiatry, 35(11), 1427-39.
Haavisto A, Sourander A, Ellila H, Valimaki M,
Santalahti P, and Helenius H (2003). Suicidal ideation and suicide
attempts among child and adolescent psychiatric inpatients in
Finland. J Affect.Disord. 76 (1-3), 211-221; Ryan ND, Puig-Antich
J, Ambrosini P, Rabinovich H, Robinson D, Nelson B, et al. (1987).
The clinical picture of major depression in children and adolescents.
Arch Gen Psychiatry, 44, 854-861; Patton GC, Coffey C, Posterino
M, Carlin JB, Wolfe R. (2000). Adolescent depressive disorder:
a population-based study of ICD-10 symptoms. Aust NZ JPsychiatry,
34, 741-747; Roberts RE, Lewinsohn PM, Seeley JR (1995). Symptoms
of DSM-III-R major depression in adolescence: evidence from an
epidemiological survey. J.Am.Acad.Child Adolesc.Psychiatry, 34,
1608-1617; Grunbaum JA, Kann L, Kinchen S, Ross J, Hawkins J,
Lowry R, et al. (2004). Youth risk behavior surveillance--United
States, 2003. MMWR Surveill Summ., 53, 1-96; Hallfors DD, Waller
MW, Ford CA, Halpern CT, Brodish PH, Iritani B (2004). Adolescent
depression and suicide risk: association with sex and drug behavior.
Am J Prev Med, 27, 224-231.
Roberts RE, Lewinsohn PM, Seeley JR (1995). Symptoms
of DSM-III-R major depression in adolescence: evidence from an
epidemiological survey. J Am Acad Child Adolesc Psychiatry, 34,
1608-1617; Kessler R C Walters EE (1998). Epidemiology of DSM-III-R
major depression and minor depression among adolescents and young
adults in the National Comorbidity Survey. Depress Anxiety, 7,
3-14; Wichstrom L (2000). Predictors of adolescent suicide attempts:
a nationally representative longitudinal study of Norwegian adolescents.
J Am Acad Child Adolesc Psychiatry, 39, 603-610; Fombonne E, Wostear
G, Cooper V, Harrington R, Rutter M, (2001). The Maudsley long-term
follow-up of child and adolescent depression. 2. Suicidality,
criminality and social dysfunction in adulthood. Br J Psychiatry,
179, 218-223; Haavisto A, Sourander A, Ellila H, Valimaki M, Santalahti
P, and Helenius H (2003). Suicidal ideation and suicide attempts
among child and adolescent psychiatric inpatients in Finland.
J Affect.Disord. 76(1-3), 211-221; Ryan ND, Puig-Antich J, Ambrosini
P, Rabinovich H, Robinson D, Nelson B, et al. (1987). The clinical
picture of major depression in children and adolescents. Arch
Gen Psychiatry, 44, 854-861; Grunbaum JA, Kann L, Kinchen S, Ross
J, Hawkins J, Lowry R et al. (2004). Youth risk behavior surveillance--United
States, 2003. MMWR Surveill Summ, 53, 1-96.
Lewinsohn PM, Clarke GN, Seeley JR, and Rohde P (1994). Major
depression in community adolescents: age at onset, episode duration,
and time to recurrence. J Am Acad Child Adolesc Psychiatry 33
March J, et al (2004). Fluoxetine, Cognitive
Behavioral Therapy, and their combination for adolescents with
depression: Treatment for Adolescents with Depression Study (TADS)
randomized controlled trial. JAMA 292(7), 807-820
Emslie GJ, Rush AJ, Weinberg WA, et al. (1997).
A double-blind, randomized, placebo-controlled trial of fluoxetine
in children and adolescents with depression. Arch General Psychiatry
Emslie GJ, Heiligenstein JH, Wagner KD et al.
(2002). Fluoxetine for acute treatment of depression in children
and adolescents: a placebo-controlled, randomized clinical trial.
J Am Acad Child Adolesc Psychiatry 41(10), 1205-15.
Lewinsohn PM, Clarke GN, Seeley JR, and Rohde
P (1994). Major depression in community adolescents: age at onset,
episode duration, and time to recurrence. J. Am. Acad. Child Adolesc
.Psychiatry 33 (6), 809-818.
Kessler RC, Avenevoli S, Merikangas KR (2001).
Mood disorders in children and adolescents: an epidemiologic perspective.
Biol Psychiatry 49(12), 1002-1014.
E. Fombonne, G. Wostear, V. Cooper, R. Harrington,
and M. Rutter. (2001). The Maudsley long-term follow-up of child
and adolescent depression. 2. Suicidality, criminality and social
dysfunction in adulthood. Br J Psychiatry 179, 218-23; Rao M,
Weissman M, Martin JA, Hammond RW (1993). Childhood depression
and risk of suicide: a preliminary report of a longitudinal study.
J Am Acad Child Adolesc Psychiatry 32(1), 21-27.
Hammad. Results of the Analysis of Suicidality in Pediatric Trials
of Newer Antidepressants. Presentation at the FDA Center for Drug
Evaluation and Research (CDER), Bethesda, MD. September 13, 2004.
Available at: http://www.fda.gov/ohrms/dockets/ac/cder04.html#PsychopharmacologidDrugs.
Accessed January 5, 2005.
Gould MS, Velting D, Kleinman M, Lucas C, Thomas
JG, Chung M (2004). Teenagers’ attitudes about coping strategies
and help-seeking behavior for suicidality. J Am Acad Child Adolesc
Psychiatry, 43(9), 1124-33.
Olfson M, Shaffer D, Marcus SC, Greenberg T.
(2003). Relationship between antidepressant medication treatment
and suicide in adolescents. Arch Gen Psychiatry 60, 978-982.
Psychiatric Association (2004). Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV-TR). Washington, DC:
American Psychiatric Association.
American Academy of Child and Adolescent Psychiatry
(1998), Practice Parameters for the Assessment and Treatment of
Children and Adolescents with Depressive Disorders. J Am Acad
Child Adolesc Psychiatry, 37(10suppl), 63s-83s.
Pfeffer CR (2001). Diagnosis of childhood and
adolescent suicidal behavior: unmet needs for suicide prevention.
Biological Psychiatry, 49, 1055-1061.
American Psychiatric Association (2000). Practice
Guideline for the Treatment of Patients with Major Depressive
Disorder (Revision). Am J Psychiatry 157(4), suppl:1-45.
Elkin I, Gibbons ID, Shea T, et al. (1995).
Initial severity and differential treatment outcome in the National
Institute of Mental Health Treatment of Depression Collaborative
Research Program. J Consult Clin Psychol, 63, 841-847.
Brent DA, Holder D, Kolko D, et al (1997). A
clinical psychotherapy trial for adolescent depression comparing
cognitive, family, and supportive therapy. Arch Gen Psychiatry
Geller B (1994). Should tricyclic antidepressants
be prescribed to depressed children and adolescents? Curr Opin
Psyhiatry 7, 301-303.
Fawcett J et al (1987). Clinical management-imipramine/placebo
administration manual: NIMH Treatment of Depression Collaborative
Research Program. Psychopharmacology Bulletin, 23, 309-324.
information contained in this guide is not intended as, and is not,
a substitute for professional medical advice. All decisions about
clinical care should be made in consultation with a child's treating
pharmaceutical funding was used in the preparation and maintenance
of this guide or the Web site ParentsMedGuide.org.
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