Treatment of depression

Summary of treatment options
Treatment depends on the type and severity of the depression.

Family or whanau problems can be a contributor to childhood depression and most doctors or other health professionals believe they cannot treat depression in children without involving the family or whanau as a whole.

This is particularly true of younger children whose depression may be a way of expressing that all is not well in the family or whanau. However, we shouldn't assume that all depression is related to family issues or problems. Other factors need to be considered, especially with adolescents or if the depression is severe.

Trust and confidentiality can be a big issue in any kind of therapy or counselling with teenagers. It is often a good idea for them to have their own counsellor or therapist if the family or whanau is also being seen for treatment. Most counsellors feel it is best to match the gender of the young person and the therapist, ie, girls to see female therapists and boys to see males.

No counsellor or therapist should keep secret a child or adolescent's expressed intentions to commit suicide. This can sometimes be difficult, but for everyone's wellbeing and safety, the young person's agreement needs to be obtained to let adult/s responsible for his or her care to know how he or she is feeling.
 
As with all child and adolescent mental health problems, a package of treatments works best. This may include some or all of the following components:

Psychosocial treatments

Psychosocial treatments are non-medical treatments which look at the child or young person's thinking, behaviour, relationships and environment, including their culture. Psychological therapies (often referred to as therapy or psychotherapy) are offered by a trained professional who uses well-researched techniques, usually talking therapies, to help young people understand what has happened to them and to make positive changes in their lives.

They may use cognitive-behavioural therapy (CBT), which largely looks at how to get rid of unhelpful beliefs, or interpersonal therapy (ITP) which looks at relationships. There is evidence to suggest that individual cognitive-behavioural therapy is more effective than other forms of therapy (including drug therapy and family therapy), for adolescents with depression. Cognitive behavioural techniques are also beginning to be adapted for use with younger children.

Although they have not been scientifically proven in the way that behaviour therapy and CBT have, two other types of therapy may be suggested in the treatment of depression. Family therapy, either as a treatment on its own, or in addition to a cognitive-behavioural programme, can be helpful to some families and whanau.

For children up to around age 12, child psychotherapy, (sometimes incorrectly referred to as play therapy as it takes place in a playroom) is offered in some centres to help the child to work through and develop mastery over emotional difficulties or stressful life events which may underlie or trigger their depression. Individual therapy with young children should always include regular consultation with their parents or guardians.

For mild depression, counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem-solving and information giving or psychoeducation. Sometimes young people are able to learn psychosocial skills such as relaxation, social skills and assertiveness either with a counsellor/therapist alone or in a group.

All types of therapy/counselling should be provided to children, adolescents and their families and whanau in a manner which is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.

Medication

Antidepressant medications are often prescribed when depression is severe. It is often used along with therapy. There is no way to predict which medication will be effective and tolerated (have fewer troublesome side effects) by any one person.

Anyone prescribed medication is entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long they will have to be taken for and what their side effects (short and long-term) are.

If you are pregnant or breast-feeding no medication is entirely safe, therefore, before making any decisions about taking medication in pregnancy you should talk with your doctor about the potential benefits and problems associated with each particular type of medication in pregnancy.

Complementary therapies

Complementary therapies which enhance the young person's life may be used in addition to psychosocial treatments and prescription medicines.

Psychosocial treatments

Psychological therapies
Psychological therapies have been found to be effective in the treatment of depression. Often they will be recommended in addition to medication, or as an alternative to medication in the case of less severe depression or where someone does not choose medication. Therapy may be held on a one-to-one basis, include families and whanau or partners for some sessions, or be held in a group.

The focus of psychotherapy or counselling in treatment of depression is on education and support for the person to understand what is happening to them, to learn coping strategies, and to get well again.

Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) have been clinically researched and found to be effective in the treatment of depression for adults and have been modified for use with adolescents, and in the case of CBT, even younger children.

Cognitive-behavioural therapy (CBT)
The basic theory of cognitive-behavioural therapy is that our thoughts and beliefs influence our feelings and behaviour. Treatment focuses on identifying specific negative thoughts and actions, and developing ways to change these. The cognitive part of the therapy helps the young person to identify and challenge these thoughts.

The therapist may then encourage activities or behaviours to help lift the mood, such as going for a short walk or doing some small thing which the child or young person used to enjoy. These activities are often given as small homework tasks. CBT also incorporates other techniques useful in helping depression such as teaching relaxation skills, stress management, assertiveness training and problem-solving techniques.

There is some evidence that CBT can be more effective than antidepressants for milder depression in adolescents (unlike studies for adult depression where antidepressants and CBT have been found to be about equal in helping people recover from depression). Unlike antidepressants, however, which are only effective as long as they are taken, the benefits of CBT may protect people against future episodes of depression.

Treatment is usually time limited and may include eight to 12 sessions over three to six months.

Interpersonal therapy (IPT)
This therapy is based on the theory that depression may be triggered by difficulties in our relationships with others. These difficulties are often increased when someone is depressed, so IPT aims to identify the interpersonal difficulties very clearly. Typical problems can include conflict in relationships, changes in roles and relationships, grief after loss of a relationship (such as breaking up with a partner) or social isolation.

The therapist spends time working with the person to develop ways to overcome their difficulties, and to find ways of relating to others which work better for the person. As with CBT, specific techniques such as effective communication skills, assertiveness, and problem-solving may be taught.

ITP is a time limited, focused treatment which may include up to 16 sessions. Research studies have found it to be effective in the treatment of depression in adults.

Treatment for severe depression may be available free of charge at a specialist child, family and adolescent clinic attached to a public hospital, where they are available. At a number of community service agencies, charges are based on ability to pay. Private therapists' fees may range from $60 to $200 per session but many also have a sliding scale of fees.

Family therapy
Family therapy looks at the whole family or whanau as a system and may see the depression as a symptom of something breaking down in that system. It certainly makes sense to think that when one person in a family or whanau is hurting with depression it will have an effect on other family or whanau members.

Family or whanau therapy encourages family or whanau members to look at their strengths, and can often be challenging as it highlights issues that other members of the family or whanau may be having which may be contributing to the depressed person's condition.

A family therapist may want to work with the child or adolescent on their own for some sessions, giving them the opportunity to talk without the family or whanau being present, as well as a number of regular sessions for the parents and other family or whanau members.

Some family therapists work singly, some with a co-therapist and some use one-way mirrors with other therapists watching the session from an adjoining room, in order to get a better appreciation of the family or whanau interactions.

There are several 'schools' of family therapy, each with slightly different ideas on how family relationships can be helped to improve. Although many families and whanau find it helpful, family therapy has never been scientifically proven as to its overall effectiveness. Unlike CBT, there are no studies to show whether family therapy helps with depression or not.

Some community agencies, such as child and family mental health clinics attached to public hospital services, offer family therapy free of charge. Family therapists in other agencies and in private practice often have a sliding scale of fees. An average cost would be from $80 to $200 per session. The number of sessions will depend on the family or whanau's needs and ability to attend.

Child psychotherapy
For younger, pre-teenage children, playroom-based child psychotherapy can help them to work through and develop mastery over emotional difficulties or stressful life events which may underlie or trigger their depression. Individual therapy with young children should always include consultation with their parents or guardians.

Child psychotherapists usually recommend up to 12 sessions.

There are currently few trained child psychotherapists in New Zealand, although it is a widely accepted approach elsewhere. Unlike CBT, there are no studies to show whether child psychotherapy helps with depression or not.

Child psychotherapists sometimes work from community child and family mental health clinics where services are free of charge. Some work in other community agencies or in private practice. Fee scales tend to be similar to those of psychologists and family therapists.

Psychoeducation
Psychoeducation is a way that young person and their family or whanau have the opportunity to learn about depression, how it is treated and about how to work together to help the person with depression to recover. It is usually provided by a health professional such as a doctor, or counsellor.

With the young person and their family or whanau they identify ways of dealing with symptoms, difficult to understand behaviour, and dealing with stress. The early signs which indicate a possible relapse are identified and a plan of early response developed. There is also attention to the kinds of support that everyone needs, and how to get this support.

Problem solving
This involves teaching the person to use their own skills and resources to cope with problems and worries. It is as effective as antidepressants for milder forms of depression, and is usually given over six to eight weekly sessions.

It has the advantage of being able to be used in a general practice setting (which is where most people with depression are seen), although as mentioned above, it may be used by a therapist or counsellor along with specific therapies for depression.

The steps in problem solving are:

• identify and clarify the problem
• set clear achievable goals
• brainstorm solutions
• select the preferred option
• evaluate progress in putting the chosen option into action.

Psychosocial skills training
While individual counsellors or therapists may teach the following skills in individual therapy, they are often provided in a group setting.

Examples of such groups include:

• Relaxation training, learning techniques of physical and mental relaxation to help counter the effects of stress.
• Stress management training, to minimise any adverse effects of stress.
• Social skills training, learning specific skills for relating to other people in social situations, and gaining confidence in such situations.
• Communication skills training, learning to communicate in a clear and concise way and ensure that the listener has understood what was intended.
• Assertion training, learning techniques for asserting one's views and needs in a way which is acceptable and respectful to others. While training in these skills alone is not effective in treating depression, it can be an extremely important aspect of helping people to recover.

Medication

Antidepressants
Antidepressant medications can be useful in treating certain cases of depression. Antidepressants are not magic pills. In other than the biological type of depression, they treat symptoms rather than causes. However, treating symptoms is most  important when the depression causes hopelessness, despair and suicidal feelings. Antidepressants can lift the young person's mood enough for them to begin to help themselves to get better.

Selective serotonin re-uptake inhibitors (SSRIs)
More recently, newer antidepressants, the Selective Serotonin Re-uptake Inhibitors (SSRIs), seem to be showing better results and have increasingly been used to treat children and adolescents. They are generally much easier to tolerate without the severe and possibly dangerous side effects of tricyclics (see below).

Side effects of SSRIs

• Nausea. Sometimes this can be reduced by taking the medication with food
• Headache. Sometimes this is an initial effect which wears off
• Sleeping trouble. SSRIs may make the sleep problems of depression worse, though as the medicine works, sleep will improve
• Agitated or jittery feeling. While not common, this can be distressing. It tends to reduce with time, but may mean a change of medicine is needed
• Rash. This is not common, but means the medication should be stopped
• Sexual problems are the most common side effect and affect up to 20 per cent of people
• Some people lose weight on SSRIs.

Antidepressants are not addictive. Apart from the risk of the depression recurring, there are usually no withdrawal effects, although if stopped suddenly there may be mild symptoms such as feeling shaky.

Antidepressants are usually continued for at least 12 months, although some people need to stay on them longer. Severe depression can interfere with normal childhood development and sometimes needs long term medication.

Different types of antidepressants should not be mixed, unless instructed by a doctor, as this could be very dangerous. Caution should be used in combining any antidepressants with other medications, alcohol or recreational drugs. Tricyclics are dangerous in overdose. Prescription drugs should be kept in a safe place by parent or caregiver if there are any concerns for the young person's safety.

Tricyclic antidepressants (tricyclics/TCAs)
Antidepressant medications have been widely used and studied in children and adolescents with depression. The older style tricyclic antidepressants such as imipramine and amitryptiline work by increasing the amounts of noradrenaline and serotonin, two brain chemical messengers which seem to be reduced when a person has depression.
 
Unlike adults, studies of tricyclic use for depression in children has shown them to be not very effective, and potentially more risky with cardiac conduction side effects. This may mean that children's depression is more severe than adults and therefore more resistant to drug treatment, that their biochemical systems are immature or different, or that children's recovery is limited by other mental health problems (as well as the depression).

In any event, there is an increasing body of evidence pointing away from using tricyclic antidepressants in children and young people, due to the risk/benefit ratio, unless there is extremely good reason.

Common side effects of tricyclic antidepressants:

• Drowsiness and loss of energy
• Dizziness
• Dry mouth. Water and sugar-free gum are good ways to reduce this
• Constipation. Plenty of liquids, fruit and vegetables can reduce this
• Blurred vision. This may mean reduction or change of medication is needed
• Increased sweating. While many people notice this, most are not troubled by it
• Weight gain. Exercise and a healthy diet are the best ways to minimise this.

Serious side effects of tricyclic antidepressants:

• Heart problems. This is usually only in people who already have heart problems, or are elderly.
• Symptoms of, or worsening of symptoms of psychosis. This is rare.
• Overdose. These drugs are very dangerous in overdose due to their effects on the heart.

There have been rare overseas reports of sudden death in children treated with tricyclics, especially desipramine in high doses (higher than 200 mg) and where there were other health problems. The concern about these side effects and the limited scientific evidence has meant they are being used less and less frequently to treat child and adolescent depression in New Zealand.

Mood stabilising medications
For children and adolescents with bipolar disorder (manic depression), drugs to stabilise mood such as lithium carbonate, carbamazepine, and sodium valproate are used. The use of these drugs for children and adolescents is largely the same as for adults.

Hospital treatment

It is very important that in any assessment for depression, the risk of suicide is honestly considered by all involved and plans made to do as much as possible to ensure the safety of the young person with depression.

This may mean they go to hospital for a short period to get treatment started, particularly when the depression is severe or there is bipolar disorder (manic depression). The availability of hospital-based programmes (inpatient and day patient) varies in each centre.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it.

There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms. This is often referred to as an holistic approach. 

Complementary therapies often support an holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs.
 
Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing.  Rongoa Maori is the indigenous health and healing practice of New Zealand.  Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Islands' people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress. Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions. It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other.
 
When considering taking any supplement, herbal or medicinal preparation it is advisable to consult a doctor to make sure it is safe and will not harm your health.
 
Girls who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and that they will not harm their own or their baby's health.

See also: Depression in childhood/adolescence; Depression in childhood/adolescence - living with

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, June 2005.