Studies of Childhood
Depression
A review of the literature was conducted to identify empirical
studies of psychosocial and pharmacological treatments of children with
depression. This review was conducted in two stages. First, systematic
computerized literature searchers were conducted on PsycINFO and Medline
databases, with keywords depression and major depression. The resulting
list of references was reduced to include only those studies that: (1)
were identified in the electronic database by one or more of the following
study descriptors: treatment outcome study, clinical trial, controlled
clinical trial, or randomized controlled trial; (2) included subjects
between the ages of 6 and 12 as the primary treatment target population,
although studies that included younger children and adolescents were
not excluded; (3) were published between 1985 and 1999; and (4) were
published in the English language. Second, reference lists obtained
from review articles and book chapters were searched to ensure that
all of the relevant studies had been identified. This search strategy
resulted in 28 potential studies. This list was further reduced by excluding
studies for the following reasons: depression was a secondary comorbid
diagnosis (e.g., mentally retarded children, socially anxious children,
medically ill children; n = 4); the study focus was
other than treatment outcome (e.g., effects of extended evaluation on
symptoms of depression, factors related to correspondence to teacher
and child ratings, information processing in recovered depressed children;
n = 4); or subjects were not randomly assigned to treatment conditions
(n = 1). This process identified 19 peer-reviewed controlled
studies of children with either depression or depressive symptoms. These
studies are presented and described in table 2.
Perhaps the most striking conclusion that can be drawn
from the current review of empirical studies of childhood depression
is the relative paucity of well-controlled outcome studies with this
population. Psychosocial and pharmacological interventions are the two
primary treatment modalities that have been studied. The psychosocial
interventions investigated include individual and group cognitive behavior
therapy, self-control training, and problem-solving and social skills
training. The pharmacological interventions include tricyclic antidepressants
(imipramine, nortriptyline), selective serotonin reuptake inhibitors
(fluoxetine), and phenethylamine monoamine reuptake inhibitors (venlafaxine).
Generally, it can be concluded that both cognitive behavior
therapy and self-control therapy are efficacious treatments for children
with symptoms of depression. However, with few exceptions, the inclusion
criteria for psychosocial treatments were based on depressive symptoms
rather than a diagnosis of depression, and treatments usually occurred
in school settings with an average of 12 sessions. Few of these studies
reported followup data. In the few studies reporting longitudinal data,
treatment gains were maintained at followup.
Research addressing the efficacy of tricyclic antidepressants
for the treatment of childhood depression failed to find superiority
for its use over placebo. Thus, there is no evidence to suggest that
tricyclic antidepressants should be used in the treatment of children
with depression. However, studies investigating the effectiveness of
selective serotonin reuptake inhibitors are promising. One recent double-blind,
placebo-controlled study of fluoxetine for childhood depression reported
significant treatment effects relative to placebo. A second new generation
antidepressant venlafaxine (a phenethylamine monoamine reuptake inhibitor)
has not been found beneficial for this population. Well designed studies
regarding the safety, efficacy, and long-term use of antidepressant
medication need to be conducted before strong statements can be made
regarding their overall efficacy in the treatment of childhood depression.
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| Table 2.1 Psychosocial
Studies of Childhood Depression |
| Study
Citation(s) |
Study
Design/
Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Butler, Miezitis, Friedman,
& Cole, 1980 |
Quasi-experimental design;
10-session school-based group treatment for depression; role-playing
(n = 14) vs. cognitive restructuring
(n = 14) vs. attention-placebo (n =
13) vs. classroom control (n = 14) |
Nondiagnosed schoolchildren
with mild to moderate depressive symptoms; subjects selected on
the basis of self-report and teacher referral |
Age: 11 – 12
Gender:
63% boys
37% girls
Race/Ethnicity: DK
|
Role-playing and cognitive
restructuring groups showed most improvement |
No followup data; method
of assignment to groups unspecified; no standard diagnostic criteria |
| Jaycox, Reivich, Gillham,
& Seligman, 1994; Gillham, Reivich, Jaycox, & Seligman,
1995 |
Quasi-experimental design;
12 session school-based group treatment; cognitive training and
social problem-solving (n = 69) vs. wait-list and
no participation control (n = 74) |
Non-diagnosed school children
identified as at-risk (current level of depressive symptoms and
parental conflict) on the basis of self-report measures |
Age: 10 – 13
Gender:
54% boys
46% girls
Race/Ethnicity:
83% White
11% African American
6% Other
|
Treatment group showed
significant decrease in and prevention of depressive symptoms
relative to control group; no between-group differences in internalizing
and externalizing behavioral problems and explanatory style |
Treatment gains maintained
at 6-month followup; treatment effects grew larger at 2-year followup;
no standard diagnostic criteria |
| Kahn, Kehle, Jenson, &
Clark, 1990 |
RCT; 12-session school-based
group treatment; cognitive-behavioral therapy (n = 17)
vs. relaxation training (n = 17) vs.
self-modeling treatment (n = 17) vs. wait-list
control |
Nondiagnosed schoolchildren
with mild to moderate depressive symptoms; subjects selected on
the basis of self-report measures and structured clinical interview |
Age: 10 – 14
Gender:
48% boys
52% girls
Race/Ethnicity: DK
|
All active treatment conditions
showed decrease in depressive symptoms and increase in self-esteem
relative to wait-list control |
Treatment effects maintained
at 4-week followup; subjects in cognitive-behavioral group showed
most improvement; subjects in self-modeling group more likely
to relapse; small sample size |
| Liddle & Spence, 1990 |
RCT; 8-session school-based
group treatment; social competence training (n = 11) vs.
attention placebo
(n = 10) vs. wait-list control (n = 10) |
Nondiagnosed schoolchildren
with mild to moderate depressive symptoms; subjects selected on
the basis of self-report measures and nonstandardized clinical
interview |
Age: 7 – 11
Gender:
68% boys
32% girls
Race/Ethnicity: DK
|
All groups showed decrease
in depressive symptoms; no significant between-group differences |
Treatment effects maintained
at 8-week followup; no standard diagnostic criteria; small sample
size |
| Stark, Reynolds, &
Kaslow, 1987 |
RCT; 12-session school-based
group treatment; self-control training (n = 9) vs.
behavioral problem-solving (n = 10) vs. wait-list
control (n = 9) |
Nondiagnosed schoolchildren
with mild to moderate depressive symptoms; subjects selected on
the basis of self-report measures and semi-structured interview |
Age: 9 – 12
Gender:
57% boys
43% girls
Race/Ethnicity: DK
|
Both active treatments
showed significant improvement relative to wait-list control |
Treatment effects maintained
at 8-week followup; small sample size; no standard diagnostic
criteria |
| Stark, Rouse, & Livingston,
1991 |
RCT; 24- to 26-session
school-based group and home treatment; cognitive-behavioral group
treatment (n = 12) vs. traditional group counseling
(n = 12) |
Nondiagnosed schoolchildren
with mild to moderate depressive symptoms; subjects selected on
the basis of self-report measures |
Age: 9 – 13
Gender: DK
Race/Ethnicity: DK
|
Within-group analyses
showed a reduction in depressive symptoms in both treatment groups;
between-group analyses showed that cognitive-behavioral group
was superior to traditional group counseling |
No between-group differences
at 7-month followup; no standard diagnostic criteria |
| Vostanis, Feehan, Grattan,
& Bickerton, 1996; Vostanis, Feehan, Grattan, & Bickerton,
1996; Vostanis, Feehan, & Grattan, 1998 |
RCT; 9-session outpatient
clinic-based individual treatment; cognitive-behavioral (n
= 29) vs. nonfocused intervention
(n = 28) |
Inpatient depressed children;
subjects selected on the basis of self-report measures and semi-structured
interview |
Age: 8 – 17
Gender:
44% boys
56% girls
Race/Ethnicity:
88% White
9% Asian
3% African American
|
Both groups showed decrease
in depressive symptoms and improvement in social functioning |
Treatment gains for both
groups were maintained at 9-month and 2-year followup; same therapists
presented both treatments; no measure of treatment adherence |
| Weisz, Thurber, Sweeney,
Proffitt, & LeGagnoux, 1997 |
RCT; 8-session school-based
group treatment; cognitive-behavioral treatment (n = 16)
vs. no treatment control (n = 32) |
Nondiagnosed schoolchildren
with mild to moderate depressive symptoms; subjects selected on
the basis of self-report measures and semi-structured interview |
Age: 8 – 12
Gender:
54% boys
46% girls
Race/Ethnicity:
63% White
37% African American
|
Treatment group showed
significant decrease in depressive symptoms relative to no treatment
control |
Treatment effects maintained
at 9-month followup; small sample size; no attention placebo control
group |
| Wood, Harrington, &
Moore, 1996 |
RCT; outpatient clinic-based
individual treatment; cognitive-behavioral treatment (n
= 24) vs. relaxation training control
(n = 24) |
Outpatient depressed children;
subjects selected on the basis of standardized semi-structured
interview |
Age: 9 – 17
Gender:
31% boys
69% girls
Race/Ethnicity: DK
|
Treatment group showed
significant decrease in depressive symptoms relative to relaxation
training control; no between-group differences on measures of
anxiety and conduct symptoms |
Between-group differences
were smaller at 3-month followup; groups did not differ at 6-month
followup |
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|
Table 2.2 Psychopharmacological
Treatments of Childhood Depression |
| Study
Citation(s) |
Study
Design/
Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Emslie, Rush, Weinberg,
Kowatch, Hughes, Carmody, & Rintelmann, 1997; Emslie, Rush,
Weinberg, Kowatch, Carmody, & Mayes, 1998 |
Double-blind, placebo-controlled
RCT; 8-week fluoxetine (n = 48) vs. placebo (n
= 48) |
Outpatient depressed children
and adolescents; subjects selected on the basis of standardized
semi-structured interview |
Age: 7 – 17
Gender:
54% boys
46% girls
Race/Ethnicity:
73% White
27% Other
|
Significant decrease in
depressive symptoms for fluoxetine vs. placebo; differences
were evident at week 5 |
Between-group differences
were less evident on self-report measures |
| Geller, Cooper, McCombs,
Graham, & Wells, 1989 |
Double-blind, placebo-controlled
RCT; 8-week nortriptyline (n = 26) vs. placebo (n
= 24) |
Outpatient depressed children;
subjects selected on the basis of standardized semi-structured
interview |
Age: 5 – 12
Gender:
70% boys
30% girls
Race/Ethnicity:
90% White
10% Other
|
No significance difference
in response rate between nortriptyline and placebo groups |
No followup data; small
sample size |
| Hughes, Preskorn, Weller,
Weller, Hassanein, & Tucker, 1990 |
Double-blind, placebo-controlled
RCT; 6-week imipramine in children with pure depression or depression
plus anxiety (n = 14) vs. children with depression
plus conduct/oppositional disorder (n = 17) vs.
placebo |
Inpatient depressed children
with comorbid anxiety or conduct/oppositional disorder; subjects
selected on the basis of consensus diagnosis using self-report
measures and a semi-structured interview |
Age: 6 – 12
Gender: DK
Race/Ethnicity: DK
|
Both depression groups
improved; higher placebo response rate among depressed children
with conduct/oppositional disorder |
No followup; small sample
size |
| Mandoki, Tapia, Tapia,
Sumner, & Parker, 1997 |
Double-blind, placebo-controlled
RCT; 6-week venlafaxine and psychotherapy (n = 16) vs.
placebo and psychotherapy (n = 17) |
Outpatient depressed children
and adolescents; subjects selected on the basis of clinician interview |
Age: 8 – 18
Gender:
25% boys
75% girls
Race/Ethnicity: DK
|
No significance difference
in response rate between the two treatment groups |
No followup data; no standard
diagnostic criteria; small sample size |
| Preskorn, Weller, Hughes,
Weller, & Bolte, 1987 |
Double-blind, placebo-controlled
RCT; 6-week imipramine (n = 10) vs. placebo (n
= 12) |
Inpatient depressed children;
subjects selected on the basis of unstructured and standardized
clinical interviews |
Age: 6 – 12
Gender: DK
Race/Ethnicity: DK
|
Significant reduction
in depressive symptoms for imipramine group relative to placebo
group |
Treatment effect detected
within 3 weeks of starting drug therapy; no followup data; small
sample size |
| Puig-Antich, Perel, Lupatkin,
Chambers, Tabrizi, King, Goetz, Davies, & Stiller, 1987 |
Double-blind, placebo-controlled
RCT; 5-week imipramine (n = 16) vs. placebo (n
= 22) |
Outpatient depressed children;
subjects selected on the basis of standardized semi-structured
interview |
Age: M =
9.11, SD = 1.43
Gender:
61% boys
39% girls
Race/Ethnicity:
42% White
37% African American
21% Hispanic
|
No significance difference
in response rate between imipramine and placebo groups |
Study terminated early
due to imipramine nonresponse; high placebo response rate; small
sample size |
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References
Studies of Childhood Depression
Butler, L., Miezitis, S., Friedman, R., & Cole, E.
(1980). The effect of two school-based intervention programs on depressive
symptoms in preadolescents. American Educational Research Journal,
17, 119.
Emslie, G. J., Rush, A. J., Weinberg, W. A., Kowatch,
R. A., Hughes, C. W., Carmody, T., & Rintelmann, J. (1997). A double-blind,
randomized, placebo-controlled trial of fluoxetine in children and adolescents
with depression. Archives of General Psychiatry, 54, 1031-1037.
Emslie, G. J., Rush, A. J., Weinberg, W. A., Kowatch,
R. A., Carmody, T., & Mayes, T. L. (1998). Fluoxetine in child and
adolescent depression: Acute and maintenance treatment. Depression
and Anxiety, 7, 32-39.
Geller, B., Cooper, T. B., McCombs, H. G., Graham, D.,
& Wells, J. (1989). Double-blind, placebo-controlled study of nortriptyline
in depressed children using a "fixed plasma level" design.
Psychopharmacology Bulletin, 25, 101-108.
Gillham, J. E., Reivich, K. J., Jaycox, L. H., & Seligman,
M. E. (1995). Prevention of depressive symptoms in schoolchildren: Two-year
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Hughes, C. W., Preskorn, S. H., Weller, E., Weller, R.,
Hassanein, R., & Tucker, S. (1990). The effect of concomitant disorders
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Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman,
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Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark,
E. (1990). Comparison of cognitive-behavioral, relaxation, and self-modeling
interventions for depression among middle-school students. School
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Liddle, B., & Spence, S. H. (1990). Cognitive-behaviour
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Preskorn, S. H., Weller, E. B., Hughes, C. W., Weller,
R. A., & Bolte, K. (1987). Depression in prepubertal children: Dexamethasone
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