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Evidence-Based Reviews

How to lower suicide risk in depressed children and adolescents

To determine if hospitalization is necessary, assess patients’ risk factors, attitude toward treatment

Vol. 11, No. 05 / May 2012

Discuss this article at

Although depression affects nearly 2% of children (age ≤12) and up to 10% of adolescents (age 13 to 18),1 the disorder often is underdiagnosed and undertreated in pediatric patients.2 Treating depression in young patients is challenging. Only 30% to 40% of depressed children and adolescents who receive evidence-based treatment achieve remission.3 In addition, 50% to 70% of those who initially achieve remission will experience recurrence within 5 years.4 Suicide is the third leading cause of death among children and adolescents, and depression greatly increases the likelihood of suicide.5,6

This article reviews assessing and treating depression in children and adolescents, and how to lower suicide risk in pediatric patients.

Symptoms vary with age

Depressive symptoms vary as a function of the child’s cognitive development and social functioning. Hopelessness and vegetative and motivational symptoms may be more frequent in adolescents than in children.7

In preschool-age children, depression manifests indirectly through somatic symptoms and behavioral disturbances. In this age group, sadness or irritability are sensitive and predominant symptoms of depression.8 In older children, sadness and loss of interest in social activities may indicate depression. In adolescents, feelings of mental and physical weariness, aloneness, disconnectedness, uncertainty, vulnerability, anger, irritability, and ambivalence toward friends suggest a depressive disorder.9

Genetic predisposition to depression, poor family support, dysfunctional parenting, and individual vulnerabilities such as poor self-esteem or emotional dysregulation may increase young patients’ risk for depression.10 Peer and family support may protect against depression. Personal competence stemming from social acceptance and body image satisfaction also may be protective factors. A sense of religious and existential well-being (finding meaning and purpose in life) are significantly associated with lower rates of depression among adolescents.11

A persistent illness

The mean duration of a depressive episode in children and adolescents is 7 to 8 months.12 However, subsyndromal depressive symptoms—as well as relapse and recurrence—are common. Long-term studies indicate that many depressed adolescents experience depressive episodes into adulthood.12 Factors that may predict recurrence in adulthood include:

  • severity of depressive episodes
  • concurrent psychotic symptoms
  • suicidal thoughts
  • history of recurrent depressive episodes
  • threshold residual symptoms
  • recent stressful life events
  • adverse family environment
  • family history of depression.12

Early symptom onset, greater depression severity, suicidality, presence of comorbid anxiety, disruptive disorders, and an adverse family environment also predict longer recovery time.12 A study of depressed adolescents found that a history of recurrent depression, family history of recurrent depression, personality disorder traits, and (for girls only) conflict with parents predicted recurrence of depression in young adulthood.4 Table 1 summarizes factors that affect depression outcomes in children and adolescents.

Table 1

What affects depression outcomes in children and adolescents?




Pharmacotherapy and CBT are equally effective in younger and older adolescents.a Although age does not affect long-term treatment outcomes, older adolescents (age 18 to 19) with treatment-resistant depression may respond better to a combination of CBT and medicationb


Females are more likely to experience relapse.c However, sex does not influence response to initial treatmentc

Socioeconomic status

Adolescents with high socioeconomic status are more likely to respond to CBT

Illness characteristics

Severity of depression is the strongest predictor of poor outcome.d-f Patients with moderate depression are more likely to benefit from CBT added to medication.g However, adding CBT to medication did not affect outcomes in adolescents with self-injurious behavior.b,f Suicidal behaviors during treatment are less frequent when CBT is combined with medicationh,i

Substance abuse

Patients with substance use disorders are less likely to respond to depression treatmentf and those who continued to abuse substances during treatment are less likely to achieve remission than those who abstainb

Cognitive measures

Higher levels of hopelessness are associated with poor outcomes. For adolescents with treatment-resistant depression who experience hopelessness, adding CBT to pharmacotherapy did not provide additional benefit. Some studies have noted that adolescents with cognitive distortions are more likely to benefit from CBT plus pharmacotherapyb

Family characteristics/environment

High family stress is associated with poor treatment outcomes.f Experiencing loss and physically dangerous events does not affect depression outcomes. Trauma and history of abuse adversely effect depression treatment outcomes

CBT: cognitive-behavioral therapy

  1. Birmaher B, Brent D; AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526.
  2. Emslie GJ, Mayes T, Porta G, et al. Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes. Am J Psychiatry. 2010;167(7):782-791.
  3. Curry J, Silva S, Rohde P, et al. Recovery and recurrence following treatment for adolescent major depression. Arch Gen Psychiatry. 2011;68(3):263-269.
  4. Wilkinson P, Dubicka B, Kelvin R, et al. Treated depression in adolescents: predictors of outcome at 28 weeks. Br J Psychiatry. 2009;194(4):334-341.
  5. Curry J, Rohde P, Simons A, et al. Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45(12):1427-1439.
  6. Asarnow JR, Emslie G, Clarke G, et al. Treatment of selective serotonin reuptake inhibitor-resistant depression in adolescents: predictors and moderators of treatment response. J Am Acad Child Adolesc Psychiatry. 2009;48(3):330-339.
  7. Emslie GJ, Kennard BD, Mayes TL. Predictors of treatment response in adolescent depression. Pediatr Ann. 2011;40(6):300-306.
  8. Emslie G, Kratochvil C, Vitiello B, et al. Treatment for Adolescents with Depression Study (TADS): safety results. J Am Acad Child Adolesc Psychiatry. 2006;45(12):1440-1455.
  9. Vitiello B. Combined cognitive-behavioural therapy and pharmacotherapy for adolescent depression: does it improve outcomes compared with monotherapy? CNS Drugs. 2009;23(4):271-280.

Assessment strategies

Semi-structured interviews such as the Child and Adolescent Psychiatric Assessment, the Diagnostic Interview for Children and Adolescents, and the Kiddie Schedule for Affective Disorder and Schizophrenia are useful for assessing depression in pediatric patients (Table 2).13-16 These tools can be used to assess depression criteria based on information gathered from several sources. Many instruments can be used to assess and monitor pediatric depression, including the Children’s Depression Inventory, the Reynolds Child Depression Scales and Adolescent Depression Scales, and the Child Depression Rating Scale.

To assess suicide risk in depressed younger patients:

  • ask about emotional difficulties
  • identify lack of developmental progress
  • estimate their level of distress
  • detect impairment in functioning
  • estimate the level of danger to themselves and others.17

The best way to assess for suicidal ideation is to ask about it directly while interviewing the patient and his or her parents. Simple questions such as “Have you ever thought about killing yourself or wish you were dead?” and “Have you ever done anything on purpose to hurt or kill yourself?” can be effective.10 These questions are best placed in the middle or toward the end of a list of questions about depressive symptoms.

Adolescents may be more likely than adults to disclose information about suicidality on self-reports.6 However, self-assessment suicide scales are not a substitute for clinical assessment because they tend to be oversensitive and non-specific and lack predictive value. A positive response to either of these questions should prompt a more detailed clinical investigation. There is no evidence that asking about suicide risk increases suicidal behavior, even in high-risk youths.

Table 2

Assessing children and adolescents: 3 semi-structured interviews



Child and Adolescent Psychiatric Assessment13

For patients age 9 to 17. Assesses symptoms from the past 3 months. Administration time: 1 to 2 hours. Requires minimal interviewer experience. Assesses impairment in multiple areas (family, peers, school, leisure activities)

Diagnostic Interview for Children and Adolescents 14

Separate versions for children (age 6 to 12) and adolescents (age 13 to 17). Assesses lifetime psychopathology. Administration time: 1 to 2 hours. Interrater reliability varies (poor to good)

Kiddie Schedule for Affective Disorders and Schizophrenia15

Assesses lifetime and current psychopathology. Administration time: 35 minutes to 2.5 hours. Interrater reliability: fair to excellent16

Treatment options

Psychotherapy. Several controlled studies and meta-analyses support the efficacy of cognitive-behavioral therapy (CBT) for mild depression in pediatric patients.18-20 Two recent meta-analyses of CBT studies in depressed adolescents found the mean effect size of CBT was 0.34 to 0.35.19,21 However, a separate analysis found CBT did not have long-term benefits for depressed adolescents, particularly patients with a history of abuse.22

Interpersonal therapy also can be effective in adolescent outpatients with mild to moderate depression. One study found the effect size of psychotherapy was modest (0.36).19

Pharmacotherapy. Two meta-analyses support selective serotonin reuptake inhibitors (SSRIs) for treating mild to moderate depression in children and adolescents. One found 61% of depressed patients age <19 who received an SSRI were “much improved” or “very much improved.”23 Another meta-analysis that compared SSRIs and placebo found fluoxetine was more effective than sertraline or citalopram for depressed adolescents.24 Other studies have shown that for severe depression, the effect size of antidepressants (0.69) is higher than that of placebo (0.39).25 Antidepressants are more effective in adolescents than in children.25

Fluoxetine is the only FDA-approved medication for treating depression in children age ≥8. In 2007 the FDA extended to all antidepressants its “black-box” warning about increased risk of suicidality in patients up to age 24. The results of studies that analyzed data about the safety of antidepressants in children and adolescents have been mixed—some found evidence of increased suicidality with antidepressant use,26,27 whereas others showed no increased risk.28,29 Table 3 summarizes steps to minimize the risk of antidepressant-induced suicidality.17

Psychotherapy plus pharmacotherapy. Researchers who compared fluoxetine to CBT and to a combination of the 2 in adolescents with moderate to severe depression found that fluoxetine was most effective in the first 12 weeks of treatment.30 Surprisingly, CBT’s effectiveness was not different from placebo.30 However, studies have shown that combining psychotherapy and medication results in greater symptom improvement,30 faster clinical response,31 improvement of global functioning and quality of life,32 and reduced suicidality.33 At 6 months, the difference in response between medication and psychotherapy was small.25 The Treatment of Resistant Depression in Adolescents study found that for chronic adolescent depression, pharmacotherapy (fluoxetine and venlafaxine) combined with CBT produced a higher response rate than pharmacotherapy alone (54% vs 41%).34

Table 3

Protecting against antidepressant-induced suicidality

Before initiating antidepressant treatment

  Review the patient’s psychiatric history

  Assess for past suicidal behavior

  Assess for a family history of mental illness or mood disorders and suicide attempts

  Screen for unrecognized bipolar spectrum disorders

  Educate patients and their families to watch for signs of worsening depression or suicidality, and to report such symptoms immediately

During antidepressant treatment

  Pay attention to abrupt changes in symptoms, particularly symptoms that were not part of the patient’s initial presentation

  Watch for deterioration of symptoms

  Monitor for emergence of ‘activating’ symptoms (ie, irritability, impulsivity, anxiety, insomnia, agitation, hostility, akathisia, hypomania, or mania)

  Evaluate the patient’s suicide risk factors, including having a specific plan and/or access to lethal means

  Consider hospitalization if the patient is at high risk for suicide

Source: Reference 17

Lowering suicide risk

Up to 60% of adolescents who commit suicide had a depressive disorder. Risk factors for child and adolescent suicide attempts include:

  • self-harm behaviors
  • psychiatric disorders
  • family disturbances
  • substance abuse
  • physical/sexual abuse.17

How to best manage suicidal youths depends on an adequate assessment of the severity of the patient’s current problems and conflicts and the degree of suicidal intent. Assessment of coping resources, access to support systems, and the attitude of the patient and family toward intervention and follow-up also is important.

Children and adolescents at high risk for suicide—those with a plan or recent suicide attempt with high probability of lethality, stated current intent to kill themselves, or recent suicidal ideation or behavior—may need inpatient psychiatric admission. Although no studies have shown that admitting high-risk suicidal patients prevents suicide, hospitalization often is the safest course of action. Develop ing a comprehensive outpatient treatment plan before discharge is essential. Patients with fewer risk factors, especially those who want help and have social support, hope for the future, and a desire to resolve conflicts, may require only a brief crisis-oriented intervention.

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