Pediatric Dysthymic Disorder Treatment & Management

  • Author: Edwin S Rogers, PhD; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Nov 18, 2011
 

Medical Care

Various types of psychotherapy (psychodynamic, cognitive-behavioral, interpersonal, family therapy) have been the mainstay of treatment of dysthymic disorder in children and adolescents. Increasing emphasis has been placed on psychopharmacology in depressed pediatric patients.[5] However, most of the recommendations for treatment with either psychotherapy or drugs are based on the adult literature. At the time of writing, controlled studies of different treatment strategies for major depressive disorder in the pediatric population have only begun to be conducted. Given the experience with adult patients that effective treatments for major depression also work for dysthymic disorder, the results from these current studies can probably inform treatment planning for children with dysthymic disorder.

Integration of psychotherapeutic treatment and psychopharmacologic treatment is typical in the adult population suffering from dysthymic disorder. In adults, studies have shown that tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) are helpful when administered at the same dosages used in the treatment of major depressive disorder. However, most of the studies of treatment in the pediatric population have used psychotherapy as the primary treatment. Very few studies on the use of pharmacotherapy alone or on combined pharmacotherapy and psychotherapy with pediatric dysthymic patients are available.

The American Academy of Child and Adolescent Psychiatry recommends that interventions that have been effective in treating major depressive disorder should be used in children and adolescents with dysthymic disease because no controlled trials and few clinical studies have been performed assessing treatment of pediatric dysthymia.[6] Because of the chronicity of dysthymic disorder (mean episode duration 3-4 y for community samples, duration at least 1 y to make the diagnosis), intense and long-term treatment may be necessary. This is particularly challenging given the arbitrary limits on insurance coverage for mental health diagnoses.

  • Psychotherapy is used to teach patients and their families to cope with stress (both current and historical), improve social skills and self-concept, understand themselves and their family, and deal with interpersonal and social conflict. In addition, it can help patients deal with the familial, academic, and occupational problems associated with depression. Psychodynamic psychotherapy, interpersonal therapy, cognitive behavioral therapy, behavior therapy, family therapy, supportive psychotherapy, and group psychotherapy have been used with depressed pediatric patients. Several factors appear to be related to the effectiveness of psychotherapy, including the following:
    • Age at onset of depression
    • Severity of depression
    • Presence of comorbid psychiatric disorders
    • Presence of or lack of support
    • Parental psychopathology
    • Significant family conflict
    • Exposure to stressful life events
    • Socioeconomic status
    • Quality of treatment
    • Therapist's expertise
    • Motivation of both patient and therapist
  • Psychodynamic psychotherapy, informed by psychoanalytic thinking, has as its goals helping patients understand themselves, identify feelings, improve self-esteem, change dysfunctional patterns of behavior, interact more appropriately with others, and manage past and ongoing conflicted relationships.
  • Interpersonal therapy focuses on interpersonal roles and difficulties. Grief, disputes, and role transitions are among issues that may be dealt with in individuals with dysthymic disorder. Improved interpersonal relationships may help lessen the possibility of relapse after treatment.
  • Cognitive behavioral therapy deals with the cognitive distortions present in the patients' views of themselves, others, and the world. Cognitive behavioral therapy systematically examines and counteracts these distortions, which contribute to the maintenance of depression. In the pediatric population, of course, intellectual and conceptual development may limit the usefulness of this technique.
  • Supportive psychotherapy offers a nurturing environment for the expression of affect. However, in one study of adolescents, it has been shown to be less effective than cognitive-behavior therapy.
  • Group psychotherapy, using various techniques, can be effective and efficient.
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Consultations

Psychotherapeutic treatment generally requires the pediatrician to make a referral to a trained mental health clinician. Child clinical psychologists, child and adolescent psychiatrists, behavioral-developmental pediatricians, child- trained clinical social workers, and professional counselors are resources for the pediatrician who encounters dysthymic patients. Given the paucity of data in children showing clear safety and efficacy of pharmacologic intervention in children with dysthymic disorder psychosocial interventions are often tried before psychopharmacological treatment is considered.

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Activity

Encouragement of developmentally appropriate play, physical exercise, and pleasurable activities are appropriate for children with anhedonia. Physical exercise has been shown to improve mood. Active play or sports (if psychologically supportive, rather than an opportunity for criticism) can accomplish these aims.

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Contributor Information and Disclosures
Author

Edwin S Rogers, PhD  Director, Behavioral Medicine Fellowship, Professor, Department of Family Medicine, University of Tennessee Medical Center at Knoxville

Edwin S Rogers, PhD is a member of the following medical societies: Association for Behavioral Science and Medical Education, North American Primary Care Research Group, and Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Steven L Spalding  MD, Staff Physician, Family Medicine, Norton Community Medical Associates

Steven L Spalding is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Carol Diane Berkowitz, MD  Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center

Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Merrily P M Poth, MD  Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences

Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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