Depression in children and adolescents

Abstract

Introduction

Depression may affect 2-8% of children and adolescents, with a peak incidence around puberty. It may be self-limiting, but about 40% of affected children experience a recurrent attack, a third of affected children will make a suicide attempt, and 3-4% will die from suicide.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of pharmacological, psychological, combination, and complementary treatments for depression in children and adolescents? What are the effects of treatments for refractory depression in children and adolescents? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: citalopram, cognitive behavioural therapy (CBT) (individual or group, to prevent relapse), escitalopram, electroconvulsive therapy, family therapy, fluoxetine (alone or with cognitive therapy or CBT), fluvoxamine, group therapeutic support (other than CBT), guided self-help, individual psychodynamic psychotherapy, interpersonal therapy, lithium, mirtazapine, monoamine oxidase inhibitors (MAOIs), omega-3 polyunsaturated fatty acids, paroxetine, sertraline (alone or with CBT), St John's Wort (Hypericum perforatum), tricyclic antidepressants, and venlafaxine.

Key Points

Depression in children and adolescents may have a more insidious onset than in adults, with irritability a more prominent feature than sadness.

• Depression may affect 2% of children and 4-8% of adolescents, with a peak incidence around puberty.

• It may be self-limiting, but about 40% of affected children experience a recurrent attack, a third of affected children will make a suicide attempt, and 3-4% will die from suicide.

Fluoxetine improves symptoms and may delay relapse over 7-12 weeks compared with placebo in children and adolescents.

• Fluoxetine may be more effective at improving symptoms compared with CBT. Combined fluoxetine plus CBT treatment may be more effective than CBT alone in adolescents.

• Fluvoxamine, citalopram, and escitalopram, have not been shown to be beneficial in adolescents and children with depression. Paroxetine and sertraline may be unlikely to be beneficial.

• We don't know whether sertraline is as effective as CBT in the treatment of adolescents. We don't know whether sertraline and CBT as monotherapies are as effective as the combination of sertraline plus CBT.

• Tricyclic antidepressants have not been shown to reduce symptoms of depression and can be toxic in overdose, so their use is not recommended.

• We do not know whether moclobemide, omega-3 polyunsaturated fatty acids, or St John's Wort are beneficial.

CAUTION: SSRIs (other than fluoxetine) and venlafaxine have been associated with serious suicide-related events in people under 18 years of age.

Group CBT in children and adolescents and interpersonal therapy in adolescents may improve symptoms in those with mild to moderate depression, but may not prevent relapse.

• We do not know whether other psychological treatments,individual CBT, group therapeutic support, interpersonal therapy in children, guided self-help, or individual psychodynamic psychotherapy improve symptoms.

We do not know whether electroconvulsive therapy or lithium are beneficial in children or adolescents with refractory depression.

About this condition

Definition

Compared with adult depression (see reviews on depression in adults: drug and other physical treatments and depression in adults: psychological treatments and care pathways), depression in children (6-12 years) and adolescents (13-18 years) may have a more insidious onset, may be characterised more by irritability than sadness, and occurs more often in association with other conditions such as anxiety, conduct disorder, hyperkinesis, and learning problems. The term "major depression" is used to distinguish discrete episodes of depression from mild, chronic (1 year or longer) low mood, or irritability, which is known as "dysthymia". The severity of depression may be defined by the level of impairment and the presence or absence of psychomotor changes and somatic symptoms (see review on depression in adults). In some studies, severity of depression is defined according to cut-off scores on depression rating scales. Definitions of refractory depression (also known as treatment-resistant depression) vary, but in this review it refers to depression that has failed to respond, or has only partially responded, to an adequate trial of at least two recognised treatments.

Incidence/ Prevalence

The prevalence of major depression is estimated to be approximately 2% in children and 4-8% in adolescents. Pre-adolescent boys and girls are affected equally by the condition, but in adolescents, depression is more common among girls than boys.

Aetiology/ Risk factors

Depression in children usually arises from a combination of genetic vulnerability, suboptimal early developmental experiences, and exposure to stresses. However, depressive syndromes sometimes occur as sequelae to physical illness, such as viral infection, and may overlap with fatigue syndromes. The heritability of depression may increase with age, but the findings from genetics studies are inconsistent. Recurrent depression seems to have a stronger familial association compared with single-episode depression. Depression-prone individuals have a cognitive style characterised by an overly pessimistic outlook on events. This cognitive style precedes the onset of depression and seems independent of recent life events and ongoing stresses. Stressful life events may trigger the first occurrence of depression, but are rarely sufficient on their own to cause depression. After a first incidence of depression, lower levels of stress are needed to provoke subsequent episodes of illness.Enduring problems in the relationship with the primary caregivers is an important risk factor for depression, but such difficulties also predispose to other psychiatric disorders.

Prognosis

In children and adolescents, the recurrence rate after a first depressive episode is 40%. Young people experiencing a moderate to severe depressive episode may be more likely than adults to have a manic episode within the following few years. Trials of treatments for child and adolescent depression have found high rates of response to placebo (as much as two thirds of people in some inpatient studies) suggesting that episodes of depression may be self-limiting in many cases. A third of young people who experience a depressive episode will make a suicide attempt at some stage, and 3-4% of those who experience depression will die from suicide.

Aims of intervention

To improve mood, social and occupational functioning, and quality of life; to reduce morbidity and mortality; to prevent recurrence of depressive disorder, with minimal adverse effects.

Outcomes

In children and adolescents, developmentally specific pseudo-continuous outcome measures such as the Children's Depression Rating Scale and the Children's Depression Inventory are available, although some studies of adolescents use scales developed for use in adults, such as the Hamilton Rating Scale for Depression. Pseudo-continuous outcome measures reported by parents, such as the Children's Depression Inventory for Parents, are also used. Categorical outcomes are sometimes expressed as people no longer meeting specified criteria for depression on a structured psychiatric interview, such as the Kiddie-Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS), which combines data from children and their parents. Global improvement in symptoms, as judged by an investigator, is sometimes reported using the Clinical Global Impressions Scale or the Children's Global Assessment Scale (see table 1 ).

Table 1.

Summary of outcome measures commonly used in trials of treatments for depression in children and adolescents (see text).

Outcome measure	Description	Scoring system
Children's Depression Rating Scale (Revised)	Semi-structured interview with child, supplemented with information from parents or significant others; assesses 17 symptoms, including those that serve as DSM criteria for depressive disorders; based on how the child has felt over previous 2 weeks. Can be used as a depression screening instrument, a confirmatory diagnostic tool, and a measure of treatment response in children. Good interrater (0.74–0.96) and test–retest (0.80–0.96) reliability, sound internal consistency (0.70), insensitive to age of child.	Items scored on a scale of 1 (least difficulties) to 5 or 7 (greatest difficulties). The summary score (range 17–113) is then transformed into a t score. Scores below 55 are unlikely to be associated with depressive disorder, scores 55–64 indicate possible risk, and scores above 65 are likely to be associated with depressive disorder.
Children's Depression Inventory	Self-report questionnaire (administrator may read aloud while child fills in) consisting of 27 items. For each item, the child chooses one of three statements describing how they have felt over the previous 2 weeks. Covers most DSM criteria for depressive disorder. Can be used as a depression screening instrument, a confirmatory diagnostic tool, and a measure of treatment response in children. Variable test–retest reliability (0.38–0.87) but sound internal consistency (0.59–0.88).	Items scored on a scale of 0 (least difficulties) to 2 (greatest difficulties). An aggregate score (range 0–54) of 11 or greater is associated with depressive disorder (sensitivity 0.67, specificity 0.60). Items load onto five factors: dysphoric mood, acting out, loss of personal and social interest, self-depreciation, and vegetative symptoms.
Hamilton Rating Scale for Depression (Revised)	Designed to assess adult depressive symptomatology but has been widely used with adolescent populations. Clinician rating based on interview with person and a sef-report problem inventory. Can be used as a depression screening instrument, a confirmatory diagnostic tool, and a measure of treatment response. Excellent interrater reliability (0.90+), and moderate to good internal consistency (0.45–0.90).	Items are scored on a 3–5 point scale of 0 (absent) to 2 or 4 (clearly present/severe). An aggregate score (range 0–64) of 11 is regarded as indicative of a diagnosis of depression.
Children's Depression Inventory for Parents	Modified version of the Child Depression Inventory completed by parents, which describes the child over the previous 2 weeks. May be used as a confirmatory diagnostic tool and is sensitive to treatment response. Moderate test–retest reliability (0.54–0.75), sound internal consistency (0.82–0.85). Generally moderate to good mother–father total score correlation (0.54–0.64), but variable parent–child correlation (0.03–0.74).	Items scored on a scale of 0 (least difficulties) to 2 (greatest difficulties). An aggregate score (range 0–54) of 12 or greater is associated with depressive disorder but does not discriminate well between depression and presentations of other psychiatric conditions (sensitivity 0.87; specificity 0.24).
Kiddie-Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS)	Semi-structured diagnostic interview for children and adolescents, completed with child and parents. Covers most childhood disorders. Current and lifetime assessment versions available. Used in research trials as a standard method of diagnostic assessment. Good interrater reliability (0.86–0.89) and moderate to good test–retest reliability of individual items (0.41–0.81), and for categorical depression diagnosis (0.54). Moderate internal consistency of depression items (0.60–0.84)	Items are scored on a 2 or 3 point scale (not present, subthreshold, threshold). Some versions include a 0–6 point scale to assess severity (not at all/normal to extreme).
Clinical Global Impressions Scale	Clinician ratings to assess overall severity of symptoms in reference to baseline functioning. Interrater reliability high when clinicians are trained, and it has moderate to good test–retest reliability.	Consists of three global measures which include severity of illness (scale 1–7; “normal” to “extremely ill”); global improvement (scale 1–7; “very much improved” to “very much worse”); and the efficacy index (scale 1–4; compares improvement in symptoms to adverse effects, from “none” to “outweighs therapeutic effect”). Higher scores indicate greater symptomatology and impairment; or not much change from baseline (before treatment).
Depression Checklist Scores	Includes 10 major symptoms of depression, as used by DSM III, and as appropriate for children. Each symptom category is anchored by characteristic behaviours of that symptom. The symptom category is checked as positive if any of the presentations are evident. Has been used as a confirmatory diagnostic tool and a measure of treatment response. No information available regarding reliability or consistency.	Total scores (range 0–10) reflect the number of depressive symptoms evident. Follows a DSM approach to diagnosis: if a child has enough symptoms reaching threshold for a period of 1 month, and these represent a change from usual behaviour, then the child can be given a diagnosis of depression.
Longitudinal Interval Follow-up Evaluation Interview for DSM-III-R	Clinician-rated semistructured interview with patient, which assesses the longitudinal course of mental illness. Excellent interrater reliability for the psychiatric symptom ratings and the global assessment scores (0.90).	Sections are rated on various scales that range from 1 and have variable end points. Low scores indicate no symptomatology/high functioning, and high scores indicate severe symptomatology/diagnostic criteria met/low functioning.
Children's Global Assessment Scale	Clinician rating of the subject's most impaired level of functioning over the previous month on a hypothetical continuum of health illness, irrespective of treatment or prognosis. Test–retest reliability is high, making the instrument a good measure of change over time. Interrater reliability is only modest.	A single score is made in the range 100–1, with 0 indicating inadequate information. A score in the range 100–91 indicates superior functioning, 90–81 good functioning in all areas, 80–71 no more than slight impairment, 70–61 difficulties in a single area, 60–51 variable functioning with sporadic difficulties in several areas, 50–41 moderate degree of impairment in most or severe impairment in one area of functioning, 40–31 major impairment in functioning in several areas or unable to function in one, 30–21 unable to function in most areas, 20–11 needs considerable supervision to prevent harm to self or others, 10–1 needs constant supervision because of severely aggressive or self-destructive behaviour, or other disorder. The use of intermediary levels (e.g. 35, 58, 62) is encouraged to reflect finer grading of impairment.
Global Assessment of Functioning Scale	Clinician rating of psychological, social, and occupational functioning on a hypothetical continuum of health illness. Does not include impairment in functioning due to physical or environmental limitations. Psychometric data on children and adolescents are limited for this instrument.	A singe score is made in the range 100–1, with 0 indicating inadequate information. The scoring ranges are similar to those for the Children's Global Assessment Scale.

DSM, diagnostic and statistical manual

Methods

Clinical Evidence search and appraisal April 2008. The following databases were used to identify studies for this systematic review: Medline 1966 to April 2008, Embase 1980 to April 2008, PsycInfo 1996 to April 2008, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2008, Issue 1. Additional searches were carried out using the NHS Centre for Reviews and Dissemination (CRD) website — for the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment (HTA) database. We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for evaluation in this review were: published systematic reviews and RCTs in any language. RCTs could be blinded or open, and had to contain 20 or more individuals of whom 80% or more were followed up. There was no minimum length of follow-up required to include studies. We also did a search for cohort studies, case-control studies, case-series and case-studies on the following specific adverse effects for antidepressants: activation syndrome or switching to mania, akathisia, increase in suicide-related behaviours. In addition we use a regular surveillance protocol to capture harms alerts from organisations such as the US FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the review as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as RRs and ORs. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review, see table .

Table.

GRADE evaluation of interventions for depression in children and adolescents

Important outcomes	Symptom improvement, functional status, adverse effects
Number of studies (participants)	Outcome	Comparison	Type of evidence	Quality	Consistency	Directness	Effect size	GRADE	Comment
What are the effects of pharmacological treatments for depression in children and adolescents?
3 (536)	Symptom improvement	Fluoxetine v placebo	4	−1	0	−1	0	Low	Quality point deducted for incomplete reporting of results. Directness point deducted for unclear clinical importance of some outcomes
2 (286)	Functional status	Fluoxetine v placebo	4	−1	0	0	0	Moderate	Quality point deducted for incomplete reporting of results
1 (40)	Symptom improvement	Fluoxetine v other antidepressant	4	−3	0	−1	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and for uncertainty about method of randomisation. Directness point deducted for uncertainty about generalisability of results
1 (220)	Symptom improvement	Fluoxetine v CBT	4	−1	0	0	0	Moderate	Quality point deducted for low follow-up
2 (422)	Symptom improvement	Citalopram v placebo	4	0	0	−1	0	Moderate	Directness point deducted for narrow range of outcomes reported
1 (268)	Symptom improvement	Escitalopram v placebo	4	0	0	−1	0	Moderate	Directness point deducted for narrow range of outcomes reported
2 (164)	Symptom improvement	Mirtazapine v placebo	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (20)	Symptom improvement	MAOIs v placebo	4	−2	0	−1	0	Very low	Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for inclusion of comorbid conditions
3 (670)	Symptom improvement	Paroxetine v placebo	4	−1	−1	0	0	Low	Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results for response depending on measure used
3 (658)	Adverse effects	Paroxetine v placebo	4	−1	0	0	0	Moderate	Quality point deducted for incomplete reporting of results
2 (309)	Symptom improvement	Paroxetine v tricyclic antidepressants	4	−1	0	−1	0	Low	Quality point deducted for incomplete reporting of results. Directness point deducted for narrow range of comparators
2 (376)	Symptom improvement	Sertraline v placebo	4	−1	−1	0	0	Low	Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results for depressive symptoms
Not clear (not clear)	Functional status	Sertraline v placebo	4	−1	0	0	0	Moderate	Quality point deducted for incomplete reporting of results
1 (73)	Symptom improvement	Sertraline v CBT	4	−2	−1	0	0	Very low	Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results at different end points.
6 (3521)	Symptom improvement	Tricyclic antidepressants v placebo	4	−1	0	0	0	Moderate	Quality point deducted for incomplete reporting of results
5 (170)	Functional status	Tricyclic antidepressants v placebo	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
2 (367)	Symptom improvement	Venlafaxine v placebo	4	−1	0	−1	0	Low	Quality point deducted for incomplete reporting of results. Directness point deducted for narrow range of comparators
2 (361)	Adverse effects	Venlafaxine v placebo	4	−2	0	−1	+2	Moderate	Quality point deducted for incomplete reporting of results and unclear outcome assessment. Directness point deducted for narrow range of outcomes reported. Effect-size points added for RR above 5
What are the effects of psychological treatments for depression in children and adolescents?
6 (at least 94)	Symptom improvement	Interpersonal therapy v waiting list control (in adolescents)	4	−1	0	−1	0	Low	Quality point deducted for incomplete reporting of results. Directness point deducted for subjective outcome measure
1 (63)	Symptom improvement	Interpersonal therapy v standard care	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (63)	Functional status	Interpersonal therapy v standard care	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
At least 4 (at least 217)	Symptom improvement	Group CBT v waiting list control	4	−1	0	−2	0	Very low	Quality point deducted for incomplete reporting of results. Directness point deducted for different results for different outcome measures (remission) and combined comparison groups
2 (149)	Functional status	Group CBT v waiting list control	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (223)	Symptom improvement	Group CBT v placebo medication and clinical management	4	−2	0	0	0	Low	Quality point deducted for incomplete reporting of results and for unclear comparator
1 (39)	Symptom improvement	Individual CBT v waiting list control	4	−2	0	−1	0	Very low	Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for narrow range of comparators
1 (223)	Symptom improvement	Individual CBT v placebo medication and clinical management	4	−1	0	−1	0	Low	Quality point deducted for incomplete reporting of results. Directness point deducted for unclear comparison group
1 (48)	Symptom improvement	Individual CBT v interpersonal therapy	4	−2	0	0	0	Low	Quality points deducted for sparse data and unclear treatment duration
1 (72)	Symptom improvement	Individual CBT v family therapy	4	−2	0	0	0	Low	Quality points deducted for sparse data and unclear treatment duration
4 (256)	Symptom improvement	Individual CBT v non-directive supportive therapy	4	−1	0	−1	0	Low	Quality point deducted for unclear treatment duration. Directness points deducted for inconsistent results for different outcomes
1 (26)	Symptom improvement	Group therapeutic support v group social skills training	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (20)	Symptom improvement	Psychodynamic psychotherapy v waiting list control	4	−3	0	−1	0	Very low	Quality points deducted for sparse data, incomplete reporting of results and for quasi-randomisation. Directness point deducted for narrow range of comparators
1 (81)	Symptom improvement	Group CBT v standard care	4	−2	0	0	0	Low	Quality points deducted for sparse data and unclear comparator
1 (56)	Symptom improvement	Individual CBT v non-directive supportive therapy	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting (results/included population)
2 (69)	Symptom improvement	Booster CBT v assessment only	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting (results/included population)
1 (32)	Symptom improvement	Family therapy v waiting list control	4	−1	0	−1	0	Low	Quality point deducted for sparse data. Directness point deducted for different results for different timeframes and different outcomes (clinician rated or self-reported)
1 (70)	Symptom improvement	Family therapy v non-specific supportive therapy	4	−2	0	0	0	Low	Quality points deducted for sparse data and unclear treatment duration
1 (72)	Symptom improvement	Family therapy v individual psychodynamic pyschotherapy	4	−2	0	0	0	Low	Quality points deducted for sparse data and unclear treatment duration
1 (72)	Functional status	Family therapy v individual psychodynamic pyschotherapy	4	−3	0	0	0	Very low	Quality points deducted for sparse data, unclear treatment duration, and incomplete reporting of results
1 (70)	Symptom improvement	Family therapy v non-directive supportive therapy	4	−2	0	0	0	Low	Quality points deducted for sparse data and unclear treatment duration
1 (31)	Symptom improvement	Family therapy plus usual care v usual care alone	4	−1	0	−1	0	Low	Quality point deducted for sparse data. Directness point deducted for narrow range of comparators
What are the effects of combination treatments for depression in children and adolescents?
1 (219)	Symptom improvement	Fluoxetine plus CBT v placebo (in adolescents)	4	−1	0	0	0	Moderate	Quality point deducted for incomplete reporting of results
2 (424)	Symptom improvement	Fluoxetine plus CBT v fluoxetine alone (in adolescents)	4	−2	−1	0	0	Very low	Quality points deducted for incomplete reporting of results and low follow-up. Consistency point deducted for conflicting results between RCTs
2 (344)	Symptom improvement	Fluoxetine plus CBT v CBT alone (in adolescents)	4	−2	0	−1	0	Very low	Quality points deducted for incomplete reporting of results and low follow-up. Directness point deducted for inclusion of comorbid disorders
1 (73)	Symptom improvement	Sertraline plus CBT v sertraline alone (in adolescents)	4	−2	0	−1	0	Very low	Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for composite outcome
1 (73)	Symptom improvement	Sertraline plus CBT v CBT alone (in adolescents)	4	−2	0	−1	0	Very low	Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for composite outcome
What are the effects of complementary treatments for depression in children and adolescents?
No studies found
What are the effects of treatments for refractory depression in children and adolescents?
1 (30)	Symptom improvement	Lithium v placebo	4	−2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results

Type of evidence: 4 = RCT Consistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio

Glossary

Attachment-based family therapy

A brief structured psychotherapy directed to adolescents and their parents or caregivers. It aims to repair attachment while promoting the autonomy of the adolescent. The treatment has five specific tasks; the focus of the family is shifted from “fixing” the individual to improving family relationships; an alliance is established with the individual; parental empathy for the individual is enhanced by exploring the parents' own stressors and history of attachment failure; the individual is encouraged to express previously unexpressed anger about core conflicts; and the individual is encouraged to make successful connections outside the home (e.g. at school, with peers, and at work).

Cognitive behavioural therapy (CBT)

A brief structured treatment (20 sessions over 12–16 weeks) aimed at changing the dysfunctional beliefs and negative automatic thoughts that characterise depressive disorders. Cognitive behavioural therapy requires a high level of training for the therapist, and has been adapted for children and adolescents suffering from depression. A course of treatment is characterised by 8–12 weekly sessions, in which the therapist and the child collaborate to solve current difficulties. The treatment is structured and often directed by a manual. Treatment generally includes cognitive elements, such as the challenging of negative thoughts, and behavioural elements, such as structuring time to engage in pleasurable activity.

Guided self-help

A self-administered intervention designed to treat depression, which makes use of a range of books, self-help manuals, or internet material, that is based on an evidence based intervention and is designed specifically for the purpose.

Interpersonal therapy

A standardised form of brief psychotherapy (usually 12–16 weekly sessions) intended primarily for outpatients with unipolar non-psychotic depressive disorders. It focuses on improving the individual's interpersonal functioning and identifying the problems associated with the onset of the depressive episode. In children and adolescents, interpersonal therapy has been adapted for adolescents to address common adolescent developmental issues — for example, separation from parents, exploration of authority in relationship to parents, development of dyadic interpersonal relationships, initial experience with the death of a relative or friend, and peer pressure.

Low-quality evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Moderate-quality evidence

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Non-directive supportive therapy

Helping people to express feelings, and clarify thoughts and difficulties; therapists suggest alternative understandings and do not give direct advice but try to encourage people to solve their own problems.

Pseudo-continuous outcome measure

The strict definition of a continuous outcome is one measured on a scale that is continuously variable, good examples being height or systolic blood pressure. In addition, there is an assumption that an increase in 1 unit in one region is equivalent to an increase of 1 unit in another region of the scale. In the case of psychometric scales made up of a series of questions, the latter assumption is not always valid, in which case the scale may be referred to as a pseudo-continuous measure. Caution needs to be applied in interpreting the magnitude of change reported on such measures.

Psychodynamic psychotherapy

Psychological interventions, derived from a psychodynamic or psychoanalytic model, in which (1) the patient and therapist explore and gain insight into conflicts and how these are represented in current situations and relationships, including the therapy relationship; (2) patients are given the opportunity to explore feelings and conscious and unconscious conflicts originating in the past, with the technical focus on interpreting and working through the conflicts; (3) therapy is non-directive and patients are not taught specific skills.

Systemic behavioural family therapy

A combination of two treatment approaches that have been used effectively for dysfunctional families. In the first phase of treatment, the therapist clarifies the concerns that brought the family into treatment, and provides a series of reframing statements designed to optimise engagement in therapy and identification of dysfunctional behaviour patterns (systemic therapy). In the second phase, the family members focus on communication and problem solving skills and the alteration of family interactional patterns (family behavioural therapy).

Very low-quality evidence

Any estimate of effect is very uncertain.

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The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.