Common Mental Disorders Depression - New Zealand Doctor

Chapter 4 Management of depression in young people/rangatahi/tamariki
Evidence from other settings
Randomised controlled trials from secondary care settings 66,272 support the effectiveness
of fluoxetine for moderate to severe depression, in children and adolescents. However,
the benefits are modest and must be balanced against an approximately doubled risk
of suicidal ideation or attempt compared to placebo, from 1–2% to 2–4%. This estimate
is based on data from 13 primary studies, which in most cases carefully screened out
young people at risk and moreover collected data on adverse events retrospectively. 281
Antidepressants, including fluoxetine, are also significantly more likely to cause
discontinuation due to adverse effects than placebo. 66 As discussed in the previous section
on psychological therapies, it is unclear whether it is beneficial to add CBT to antidepressant
therapy, as the evidence is inconsistent as to whether this improves efficacy or safety.
Pharmacological therapies: issues for evidence-based practice
There is good evidence from secondary care that fluoxetine is moderately effective
for moderate to severe depression in young people/rangatahi/tamariki, but safety
concerns preclude the initiation of antidepressant treatment in a young person in
primary care without the support of a child and adolescent psychiatrist.
Complementary and alternative medicines
There was insufficient evidence to determine whether any complementary or alternative
medicines are effective for the treatment of depression in young people/rangatahi/
tamariki. A systematic review found very few RCTs and no evidence in favour of any
therapy, apart from two small studies (total n=33) providing limited support for the
use of light therapy for seasonal depression. 282
No RCTs were found on the use of St John’s Wort for depression in young people.
However, there are safety concerns about the use of St John’s Wort in adults. 283
Young people using or considering using St John’s Wort should be advised of
possible drug interactions.
There is currently great interest in the role of omega-3 polyunsaturated fatty acids
(omega-3) for the treatment of mental disorders. A recent systematic review included
a single small placebo-controlled RCT (n=28) conducted among depressed children
from 6- to 12-years of age presenting in secondary care with a first episode of
depression. 284 An over-the-counter preparation was used containing approximately
400 mg eicosapentanoic acid (EPA) and 200 mg docosahexaenoic acid (DHA),
which was given as monotherapy. There was a statistically significant reduction in
symptom scores in the group taking omega-3 compared to the placebo group at all
follow-up times from week 8 to week 16 (p≤0.041). No clinically relevant side effects
were reported, though studies of omega-3 for attention disorder in children have
reported mild gastrointestinal effects. 285 This small study supports the possibility that
omega-3 supplementation may be an effective monotherapy for childhood depression
and highlights the need for more randomised controlled trials in this area.
Identification of Common Mental Disorders and Management of Depression in Primary Care 53