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Continuation Treatment and Relapse Prevention in Pediatric Depression

(PSYCHIATRIC TIMES) - The prevalence of depression in children and adolescents ranges from 2% to 8% in the general population, which indicates that depression in this population is a major public health concern.1-3 This is especially apparent when rates of depression are compared with other serious medical conditions in childhood, such as diabetes, which has a prevalence of 0.18%.4 The burden of depressive illness—including significant functional impairment in interpersonal relationships, school, and work—on the developing child has been well documented. Affected youths are frequently involved in the juvenile justice system.5-8 Furthermore, adolescents with depression are at increased risk for substance abuse, recurrent depression in adulthood, and attempted or completed suicide.3,9-15

Acute-phase treatments for major depression in this age-group have been found to be effective; however, relapse rates range from 34% to 75%.16-19 Even with the most effective acute treatments for depression (antidepressant medication with cognitive-behavioral therapy [CBT]), remission rates are low and residual symptoms are common.20 Furthermore, approximately one-third of adolescents with depression are unable to maintain symptom remission.21 In addition to acute-phase treatments, it is becoming increasingly accepted that these patients need longer-term treatments (continuation and maintenance phase interventions). See the Table for definitions of key terms.

Risk factors related to relapse

While limited information exists on predictors of relapse in child and adolescent depression, there is evidence that the illness can be recurrent and chronic, as it can be in adults. In particular, the more severe the illness, the greater the risk of recurrence. Predictors of relapse include comorbidity, previous depressive episodes, early age at onset, suicidal thinking and behavior, poor global functioning, psychosocial stressors, family psychiatric history, and family discord.7,22-31

In the Treatment for Adolescents With Depression Study (TADS), residual symptoms at the end of acute treatment indicated a poorer outcome after acute treatment. Those patients who had symptoms at the end of 12 weeks of treatment were less likely to have symptom remission at 18 and 36 weeks.21

Cognitive variables, such as dysfunctional thinking, can predict recurrent depression, and continued cognitive distortions following treatment may predict shorter time to relapse or recurrence of symptoms.28,32

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