Continuation and maintenance therapy of early-onset major depressive disorder

Child and adolescent depression is a serious and often episodic disorder with a high rate of recurrence equal to or surpassing that of adult depression. Symptoms of depression are similar in child, adolescent, and adult populations. The diagnostic criteria are the same, with the possible exception that children and adolescents are more likely to present with irritability without clear sadness. Despite the similarities between adult, adolescent, and child depression, results of studies of psychosocial and pharmacologic treatments in adult depression are not necessarily applicable to the pediatric population. The treatment of depression has been divided into three phases: acute (leading to clinical response and remission of symptoms); continuation (prevention of symptom relapse); and maintenance (prevention of new episodes or recurrences). According to research of acute treatment of child and adolescent depression with pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment. Recent controversies have caused some concern about the use of SSRIs in children and adolescents; however, SSRIs remain the initial pharmacologic treatment of choice. Acute treatment with non-specific psychotherapy is considered an essential component in the management of depression, but has not been shown to be equally effective as pharmacotherapy or specific psychotherapies by itself. There is increasing evidence that cognitive behavior therapy and interpersonal therapy are effective for the treatment of early-onset depression. Unfortunately, severe depression, comorbid diagnoses, family discord, and increased impairment may hinder the establishment of remission; these factors have been associated with treatment resistance. Once remission of depressive symptoms is established, continuation and maintenance treatment should be considered. Only one study of continuation treatment has been completed in child and adolescent depression; the results support the use of fluoxetine as a safe and effective treatment for reducing relapse. To date, no studies have been reported on maintenance treatment with specific therapies in child and adolescent depression, but trials in adults have demonstrated the importance of continued pharmacotherapy beyond the continuation phase of the illness. Although several factors are associated with response to treatment in children and adolescents with depression, including younger age, lower severity of depressive symptoms, higher family functioning, and fewer comorbid diagnoses, few studies have consistently demonstrated predictors of relapse and recurrence.