Pediatric Persistent Depressive Disorder (Dysthymia) Treatment & Management

Updated: Oct 14, 2016
  • Author: Jeffrey S Forrest, MD; Chief Editor: Caroly Pataki, MD  more...
  • Print
Treatment

Approach Considerations

Various types of psychotherapy (psychodynamic, cognitive-behavioral, interpersonal, family therapy) have been the mainstay for treatment of persistent depressive disorder (PDD) in children and adolescents. Increasing emphasis has been placed on psychopharmacology in depressed pediatric patients. [8]

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 indicating that effective treatments for major depression also work for PDD, the results from these current studies can probably inform treatment planning for children with PDD.

Because of the lack of research into the treatment of pediatric dysthymia, the American Academy of Child and Adolescent Psychiatry (AACAP) recommends that interventions that have been effective in treating major depressive disorder be used in children and adolescents with dysthymic disease. [9]

The chronicity of PDD (mean episode duration 3-4 years for community samples; duration at least 1 y to make the diagnosis) means that intense and long-term treatment may be necessary. This is particularly challenging given the arbitrary limits on insurance coverage for mental health diagnoses.

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.

Inpatient care

Inpatient care generally is not necessary for the treatment of PDD. If major depression develops with suicidal ideation, then inpatient care may be urgently needed.

Next:

Pharmacologic Therapy

Integration of psychotherapeutic and psychopharmacologic treatments is typical in the adult population suffering from PDD. 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.

Previous
Next:

Psychotherapy

Psychotherapy is used to teach patients and their families to cope with stress (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 to 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 patient and therapist

Psychodynamic psychotherapy

Psychodynamic psychotherapy, informed by psychoanalytic thinking, has as its goals helping patients to 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

Interpersonal therapy focuses on interpersonal roles and difficulties. Grief, disputes, and role transitions are among the issues that may be dealt with in individuals with PDD. Improved interpersonal relationships may help to lessen the possibility of relapse after treatment.

Cognitive behavioral therapy

Cognitive behavioral therapy deals with the cognitive distortions present in the patients' views of themselves, others, and the world. This form of 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. [10, 11]

Supportive psychotherapy

Supportive psychotherapy offers a nurturing environment for the expression of affect. In one study of adolescents, however, it was shown to be less effective than cognitive-behavioral therapy.

Group psychotherapy

Group psychotherapy, using various techniques, can be effective and efficient.

Previous
Next:

Ongoing Care

Given the chronic nature of PDD, ongoing psychotherapeutic and/or psychopharmacologic care may be necessary to foster sustained remission and modification of maladaptive coping. Termination of cognitive behavioral therapy and interpersonal therapy, when studied in the treatment of major depression in the pediatric population, resulted in a significant relapse rate on follow-up care, suggesting the need for maintenance therapy.

Jonsson et al concluded that depression in adolescence is a good predictor of adult depression and encouraged investigation into early interventions that might alter this pattern. [12]

Previous
Next:

Deterrence and Prevention

Very few studies have been published on the prevention of depressive disorders in general in children and adolescents. Given the lengthy course of PDD, however, prevention and early intervention are key to minimizing suffering and functional impairment.

PDD is often followed by recurrent major depression; prevention and early treatment of PDD could help to prevent this more serious condition, as well as other potential future comorbidities, such as substance abuse and school failure.

The few studies that have been conducted show that group cognitive behavioral therapy, together with relaxation training and group problem-solving therapy, may prevent recurrences of subclinical depression for many months posttreatment.

Although long-term data are unavailable, brief, family-based educational interventions have also helped to prevent mood disorders in children at risk because of parental depression.

Suicide risk

Adolescent patients with PDD may develop a superimposed major depressive episode and deteriorate quickly into a more severely ill state. Such a change may be overlooked by the patient, who sometimes becomes accustomed to the chronically depressed state and may not differentiate development of an acute major depressive episode from the baseline. The emotional lability of adolescents and the intensity of their developmental state and relationships may provide sufficient stress to potentiate an impulsive suicidal act.

Unfortunately, many patients who attempt or complete suicide have seen a health care practitioner within a relatively short period before their suicide attempt. Frequent assessment of suicidal ideation and other depressive symptoms can assist the clinician in intervening appropriately. Suicide attempts are a psychiatric emergency and should be treated as such, with intensive assessment and intervention; this includes hospitalization if the patient’s safety cannot be ensured on an outpatient basis.

Previous
Next:

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 clearly showing pharmacologic intervention in children with PDD to be safe and effective, psychosocial interventions are often tried before psychopharmacologic treatment is considered. When medication is considered, consultation with a psychiatrist or behavioral pediatrician is required.

Previous