BMJ  2004;329:1396 (11 December), doi:10.1136/bmj.329.7479.1396

Commentary

abandoning the diagnosis will endanger severely depressed children

¹ Chichester Child and Adolescent Mental Health Services, Chichester PO19 6PQ spender{at}sghms.ac.uk

As a family therapist, I applaud Timimi's broadly systemic approach to childhood unhappiness.¹ In my experience, young people aged 14-16 are most likely to present to clinicians with depression, and he is right to emphasise the sociocultural roots of their unhappiness. However, I am concerned at the underemphasis on possible consequences of depression, such as school failure, social withdrawal, antisocial behaviour, substance misuse, family disharmony, and suicide, which are more than just potential comorbidities.

I agree that psychoeducation is an important component of treatment. This includes acknowledging that some life experiences can be more difficult than others, particularly losses; that sleep can be improved by exercise; that mood can be improved by activity scheduling; and that an emphasis on the positive is more likely to help than a focus on the negative. But I cannot see that this is enough; nor do I think that child mental health professionals can in general change the contexts that contribute to adolescent depression, such as schools that pressurise, parents who are too busy, or friends who are unsupportive. Is it enough to refer such young people to psychologists or psychotherapists?

The idea that the symptoms of depression in children are different from those in adults is not new. But this does not mean that treatments have to be different. On the contrary, available evidence suggests that those treatments effective for adults are also effective for adolescents.^{2 3} Despite the debate about suicidal ideation with some antidepressants, a consensus seems to have emerged that fluoxetine is both effective and safe.⁴

The danger of abandoning the diagnosis of depressive disorder is that the evidence base for effective psychological and pharmacological treatments may also be disregarded. Just because depression is on a continuum with unhappiness is hardly a reason for not setting a cut-off point for treatment. Applying the same argument to blood pressure could lead to an epidemic of preventable strokes and renal disease. Child psychiatrists who treat adolescents with severe depression know that both psychological therapies and antidepressants work: the more severe the depression, the more likely are the benefits to outweigh the risks.

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Competing interests: QS has accepted invitations from Janssen-Cilag and Eli Lilly to attend meetings about attention deficit hyperactivity disorder.

References

1. Timimi S. Rethinking childhood depression. BMJ 2004;329: 1394-6.[Free Full Text]
2. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA 2004;292: 807-20.[Abstract/Free Full Text]
3. Mufson L, Dorta KP, Wickramaratne P, Nomura Y, Olfson M, Myrna M. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry 2004;61: 577-84.[Abstract/Free Full Text]
4. Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrove A, Boddington E. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet 2004;363: 1341-5.[CrossRef][ISI][Medline]

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Rethinking childhood depression

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