Treatment of depressive illness among children and adolescents in the United States

Background: Psychotherapy has proven to be an effective treatment modality in children and adolescents with depressive illness. The American Academy of Child and Adolescent Psychiatry advocates the use of selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacotherapy in the treatment of depression without comorbid mental illness. Tricyclic antidepressants (TCAs) are not recommended as first-line treatment because of insufficient evidence of their efficacy in children and adolescents, as well as potential adverse effects. Objective: The present study was designed to determine the extent of the use of antidepressant pharmacotherapy and/or psychotherapy among children and adolescents in the United States aged 5 through 18 years with a diagnosis of depressive illness. Methods: Using data from the National Ambulatory Medical Care Survey (NAMCS) for 1990 through 1995, office-based physician-patient encounters (ie, office visits) documenting the use of antidepressant pharmacotherapy and/or a recorded diagnosis of depression were obtained. The rate per 1000 office visits for children and adolescents aged 5 through 18 years and the rate per 1000 US population aged 5 through 18 years were calculated for: (1) prescribing of antidepressant pharmacotherapy for any reason; (2) recorded diagnosis of depression with or without comorbid mental illness; (3) diagnosis of depression with or without comorbid mental illness resulting in the prescribing of antidepressant pharmacotherapy; (4) diagnosis of depression without comorbid mental illness; and (5) diagnosis of depression without comorbid mental illness resulting in the prescribing of antidepressant pharmacotherapy. Treatment modalities used in the management of depressive illness (pharmacotherapy, psychotherapy, both, or neither) are reported as percentages of the total number of office visits for the 1990-1992 period and for 1995 (the years for which data on the use of psychotherapy were recorded in the NAMCS). Results: Between 1990 and 1995, an estimated 4,638,608 office visits documented the prescribing of antidepressant pharmacotherapy for any reason in children and adolescents aged 5 through 18 years (9.0 per 1000 encounters; 15.3 per 1000 population). The majority of encounters (58.2%) documented the prescribing of a TCA. The rate of a documented diagnosis of depression with or without comorbid mental illness was 8.0 per 1000 encounters and 13.6 per 1000 population. The rate for a documented diagnosis of depression with or without comorbid mental illness, in concert with the prescribing of antidepressant pharmacotherapy, was 3.9 per 1000 encounters and 6.6 per 1000 population. The rate for a documented diagnosis of depression without comorbid mental illness was 5.1 per 1000 encounters and 8.7 per 1000 population. The rate for a documented diagnosis of depression without comorbid mental illness, in concert with the prescribing of antidepressant pharmacotherapy, was 2.6 per 1000 encounters and 4.4 per 1000 population. Of the 1,327,466 patients with a recorded diagnosis of depression without comorbid mental illness who were prescribed antidepressant pharmacotherapy, 54.9% received an SSRI, and 39.8% a TCA. During the 1990-1992 period and in 1995, the modality of treatment for patients with a documented diagnosis of depression without comorbid mental illness was antidepressant pharmacotherapy alone in 12.7% of patients, psychotherapy alone in 31.8%, psychotherapy and antidepressant pharmacotherapy in 36.0%, and neither psychotherapy nor antidepressant pharmacotherapy in 19.5%. Conclusions: The use of psychotherapy and antidepressant pharmacotherapy for the treatment of depressive illness in US children and adolescents is extensive. The use of the TCAs in patients with a documented diagnosis of depression without comorbid mental illness is widespread even though this drug class is not recommended as first-line therapy in this population. Approximately 19% of children and adolescents with a recorded diagnosis of depressive illness received neither psychotherapy nor pharmacotherapy. This finding may reflect problems associated with access to health insurance, the coverage of mental health services under insurance policies, geographic distribution of mental health services, and/or decisions by patients or guardians.