In Canada, depressive disorders are common in children as young as 10 years. Multimodal interventions may address these disorders effectively, according to a presentation given at a virtual pediatric conference held by the University of Toronto and the Hospital for Sick Children.

“Here in Canada, death by suicide is the second leading cause of death for young people ages 15-19 years and the third for young people ages 10-14 years,” said Roberto Britto Sassi, MD, PhD, psychiatrist-in-chief at BC Children’s Hospital and associate professor of psychiatry at The University of British Columbia in Vancouver. “Depression is often chronic and recurrent and has a significant impact on soc ial and academic function. There are various things that young people should be doing at a particular moment in their development that they might not be able to do because of depression.”

Less than one third of youths with depression receive any professional treatment during their depressive episode, pointed out Sassi. “Clearly, we need to do much better.”

Populations at Risk

Pediatric patients with more adverse childhood experiences are likely to become adults who are refractory to treatment for depression, according to Sassi.

“There’s a clear pattern between people who have had negative, traumatic experiences between ages 4 and 7 years, particularly sexual abuse and trauma, and the likelihood of responding to medication or therapy,” said Sassi. He cited an analysis of adults with major depressive disorder.

“If you don’t have a history of abuse in childhood, you are much more likely to be a responder and a remitter to antidepressant treatment than those who have a history of abuse or trauma,” said Sassi.

Research indicates that female youths, Indigenous youths, and nonbinary youths are more vulnerable to depression than their peers. Data from a 2024 study identified females as having worse indicators of mood, depression, and suicidality. About 22% reported that they had considered suicide in the past year. In addition, 47% of nonbinary youths seriously considered suicide in the past year. Limited data suggest that Indigenous youths have higher rates of depression and suicide than their non-Indigenous peers.

Role of Psychotherapy

Various forms of psychotherapy can be initiated and conducted in person or virtually. Data suggest no significant difference in patient acceptance between in-person and virtual therapy, according to Sassi.

“I see virtual therapy as being better than the absence of any psychotherapy options,” he said, pointing out that youths living in remote regions may be unable to access in-person psychotherapy easily.

Sassi has never known a patient to refuse in-person therapy. “If in-person therapy is available, it tends to be, from a clinical point of view, better accepted,” he said.

Which Pharmacotherapy?

When youths present with moderate-to-severe depression, or when psychological therapies are not effective or possible, clinicians can consider pharmacotherapies for managing depression, pointed out Sassi.

Health Canada has not approved any medications to treat depressive disorders in children and youth, but some selective serotonin reuptake inhibitors (SSRIs) are approved by the US Food and Drug Administration. “ When I prescribe the medications for young people with depression, I’m doing it off label, but I’m doing it based on the scientific literature,” said Sassi.

In the pediatric setting, Sassi often chooses the SSRI fluoxetine. He suggested a starting dose of 10-20 mg daily, which can be titrated to 20-80 mg daily.

If the patient responds inadequately to fluoxetine, and the clinician opts to switch to another SSRI, he or she must keep in mind that fluoxetine has a prolonged half-life. “If you’re switching to another medication, [fluoxetine] is going to linger in the body for quite some time,” said Sassi. “If you need to do a washout, it’s usually a little bit longer than what we do when switching from other medications.”

It is particularly important to avoid fluoxetine in youths who might have a family history of bipolar disorder and could be at risk for a manic episode. “If you want to stop the medication very rapidly, you cannot do that with fluoxetine, because of the long half-life,” said Sassi.

A Challenging Population

Patients who experienced hardships in childhood and have mental health challenges like depression are a challenging population to treat.

“What we call early adversity, which is trauma, abuse, and neglect, is a major predictor of not only current but also subsequent mental health problems,” said Anne Duffy, MD, an academic child and adolescent psychiatrist and professor of psychiatry at Queen’s University in Kingston, Ontario.

Given that fluoxetine has the most evidence in the pediatric setting of all SSRIs, it is the preferred choice for pediatric patients, said Duffy. She stressed the need to take the family’s mental health history before prescribing an antidepressant. “You have to be aware if this youth has several family members with confirmed bipolar disorder,” said Duffy. “You then probably wouldn’t continue an antidepressant chronically because you would be at risk for slipping them into mania.”

Sassi and Duffy had no relevant financial relationships.