Depression in childhood and adolescence
Depression is a state of low mood and aversion to activity. It may be a normal reaction to occurring life events or circumstances, a symptom of a medical condition, a side effect of drugs or medical treatments, or a symptom of certain psychiatric syndromes, such as the mood disorders major depressive disorder and dysthymia. Depression in childhood and adolescence is similar to adult major depressive disorder, although young sufferers may exhibit increased irritability or aggressive and self-destructive behavior, rather than the all-encompassing sadness associated with adult forms of depression. Children who are under stress, experience loss, or have attention, learning, behavioral, or anxiety disorders are at a higher risk for depression. Childhood depression is often comorbid with mental disorders outside of other mood disorders; most commonly anxiety disorder and conduct disorder. Depression also tends to run in families. Psychologists have developed different treatments to assist children and adolescents suffering from depression, though the legitimacy of the diagnosis of childhood depression as a psychiatric disorder, as well as the efficacy of various methods of assessment and treatment, remains controversial.
- 1 Base rates and prevalence
- 2 Diagnosis
- 3 History
- 4 Assessments
- 5 Treatment
- 6 Controversies
- 7 References
Base rates and prevalenceEdit
About 8% of children and adolescents suffer from depression. This year, 51 percent of students (teens) who visited a counseling center reported having anxiety, followed by depression (41 percent), relationship concerns (34 percent) and suicidal ideation (20.5 percent). Many students reported experiencing multiple conditions at once. Research suggests that the prevalence of young depression sufferers in Western cultures ranges from 1.9% to 3.4% among primary school children and 3.2% to 8.9% among adolescents. Studies have also found that among children diagnosed with a depressive episode, there is a 70% rate of recurrence within five years. Furthermore, 50% of children with depression will have a recurrence at least once during their adulthood. While there is no gender difference in depression rates up until age 15, after that age the rate among women doubles compared to men. However, in terms of recurrence rates and symptom severity, there is no gender difference. In an attempt to explain these findings, one theory asserts that preadolescent women, on average, have more risk factors for depression than men. These risk factors then combine with the typical stresses and challenges of adolescent development to trigger the onset of depression.
Like their adult counterparts, children and adolescent depression sufferers are at an increased risk of attempting or committing suicide. Suicide is the third leading cause of death among 15-19 year olds. Adolescent males may be at an even higher risk of suicidal behavior if they also present with a conduct disorder. In the 1990s, the National Institute of Mental Health (NIMH) found that up to 7% of adolescents who develop major depressive disorder may commit suicide as young adults. Such statistics demonstrate the importance of interventions by family and friends, as well as the importance of early diagnosis and treatment by medical staff, to prevent suicide among depressed or at-risk youth. However, some data showed an opposite conclusion. Most depression symptoms are reported more frequently by females; such as sadness (reported by 85.1% of women and 54.3% of men), and crying (approximately 63.4% of women and 42.9% of men). Women have a higher probability to experience depression than men, with the prevalences of 19.2% and 13.5% respectively.
In childhood, boys and girls appear to be at equal risk for depressive disorders; during adolescence, however, girls are twice as likely as boys to develop depression. Before adolescence rates of depression are about the same in girls and boys, it is not until between the ages of 11-13 that is begins to change. Young girls around this age, physically, go through more changes than young boys which put that a higher risk for depression and hormonal imbalance. The gender gap in depression between adolescent men and women is mostly due to young women's lower levels of positive thinking, need for approval, and self-focusing negative conditions. Frequent exposure to victimization or bullying was related to high risks of depression, ideation and suicide attempts compare to those not involved in bullying. Nicotine dependence is also associated with depression, anxiety, and poor dieting, mostly in young men. Although causal direction has not been established, involvement in any sex or drug use is cause for concern. Children who develop major depression are more likely to have a family history of the disorder (often a parent who experienced depression at an early age) than patients with adolescent- or adult-onset depression. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.[medical citation needed]
Research has shown that there is a high rate of comorbidity with depression in children with dysthymia. There is also a substantial comorbidity rate with depression in children with anxiety disorder, conduct disorder, and impaired social functioning. Particularly, there is a high comorbidity rate with anxiety, ranging from 15.9% to 75%. Conduct disorders also have a significant comorbidity with depression in children and adolescents, with a rate of 23% in one longitudinal study. Beyond other clinical disorders, there is also an association between depression in childhood and poor psychosocial and academic outcomes, as well as a higher risk for substance abuse and suicide.
The prevalence of psychiatric comorbidities during adolescence may vary by race and ethnicity.
According to the DSM-IV, children must exhibit either a depressed mood or a loss of interest or pleasure in normal activities. These activities may include school, extracurricular activities, or peer interactions. Depressive moods in children can be expressed as being unusually irritable, which may be displayed by "acting out," behaving recklessly, or often reacting with anger or hostility. Children who do not have the cognitive or language development to properly express mood states can also exhibit their mood through physical complaints such as showing sad facial expressions (frowning) and poor eye contact. A child must also exhibit four other symptoms in order to be clinically diagnosed. However, according to the Omnigraphics Health References Series: Depression Sourcebook, Third Edition, a more calculated evaluation must be given by a medical or mental health professional such as a physiologist or psychiatrist. Following the bases of symptoms, signs include, but are not limited to, an unusual change in sleep habits (for example, trouble sleeping or overly indulged sleeping hours); a significant amount of weight gain/loss by lack or excessive eating; experiencing aches/pains for no apparent reason that can found; and an inability to concentrate on tasks or activities. If these symptoms are present for a period of two weeks or longer, it is safe to make the assumption that the child, or anybody else for that matter, is falling into major depression.
Correlation between adolescent depression and adulthood obesityEdit
According to research conducted by Laura P. Richardson et al., major depression occurred in 7% of the cohort during early adolescence (11, 13, and 15 years of age) and 27% during late adolescence (18 and 21 years of age). At 26 years of age, 12% of study members were obese. After adjusting for each individual's baseline body mass index (calculated as the weight in kilograms divided by the square of height in meters), depressed late adolescent girls were at a greater than 2-fold increased risk for obesity in adulthood compared with their non-depressed female peers (relative risk, 2.32; 95% confidence interval, 1.29-3.83). A dose-response relationship between the number of episodes of depression during adolescence, and risk for adult obesity was also observed in female subjects. The association was not observed for late adolescent boys or for early adolescent boys or girls.
Correlation between child depression and adolescent cardiac risksEdit
According to research by RM Carney et al., any history of child depression influences the occurrence of adolescent cardiac risk factors, even if individuals no longer suffer from depression. They are much more likely to develop heart disease as adults.
Distinction from major depressive disorder in adultsEdit
While there are many similarities to adult depression, especially in expression of symptoms, there are many differences that create a distinction between the two diagnoses. Research has shown that when a child's age is younger at diagnosis, typically there will be a more noticeable difference in expression of symptoms from the classic signs in adult depression. One major difference between the symptoms exhibited in adults and in children is that children have higher rates of internalization; therefore, symptoms of child depression are more difficult to recognize. One major cause of this difference is that many of the neurobiological effects in the brain of adults with depression are not fully developed until adulthood. Therefore, in a neurological sense, children and adolescents express depression differently.
Professionals first became aware of child abuse in the early 1980s, so it is possible that some of the young people identified with depressive disorders may have had a history of sexual abuse, which was not disclosed. This raises the question of what the outcome would have been in those young people if they had disclosed the abuse and received appropriate therapeutic interventions. It is well known that childhood sexual abuse is a significant factor in the history of some adults with depressive syndromes.
In the past, attention deficit hyperactivity disorder (ADHD) was not recognized, and hyperkinetic disorder was only rarely diagnosed. Some young people, especially those with comorbid conduct disorder and major depressive disorder, may have had undiagnosed and untreated ADHD. Before the use of psycho-stimulants, some young people may have been more vulnerable to development of depressive syndromes because of untreated attentional and other behavioural problems which reduce their self-esteem.
Although antidepressants were used by child and adolescent psychiatrists to treat major depressive disorder, they may not always have been used in young people with a comorbid conduct disorder because of the risks of overdose in such a population. Tricyclic antidepressant were the predominant antidepressants used at that time in this population. With the advent of selective serotonin re-uptake inhibitors (SSRIs), child and adolescent psychiatrists probably began prescribing more anti-depressants in the comorbid conduct disorder/major depressive group because of the lower risk of serious harm in overdose. This raises the possibility that more effective treatment of these young people might also improve their outcomes in adult life.
Among the psychological assessments for identifying whether or not children and adolescents are experiencing depression or depressive symptoms is the Children's Depression Inventory. In early 2016, the USPSTF released an updated recommendation for the screening of adolescents ages 12 to 18 years for major depressive disorder (MDD). Appropriate treatment and follow-up should be provided for adolescents who screen positive.
There are multiple treatments that can be effective in treating children diagnosed with depression. Psychotherapy and medications are commonly used treatment options. In some research, adolescents showed a preference for psychotherapy rather than antidepressant medication for treatment. For adolescents, cognitive behavioral therapy and interpersonal therapy have been empirically supported as effective treatment options. The use of antidepressant medication in children is often seen as a last resort; however, studies have shown that a combination of psychotherapy and medication is the most effective treatment. Pediatric massage therapy may have an immediate effect on a child's emotional state at the time of the massage, but sustained effects on depression have not been identified.
Treatment programs have been developed that help reduce the symptoms of depression. These treatments focus on immediate symptom reduction by concentrating on teaching children skills pertaining to primary and secondary control. While much research is still needed to confirm this treatment program's efficacy, one study showed it to be effective in children with mild or moderate depressive symptoms.
There are a variety of common types of talk therapy. These can assist people to live more fully and have a better life. In many types, men are encouraged to open up more emotionally and communicate their personal distress, while women are encouraged to be assertive of their own strengths. Often psychotherapy teaches coping skills while allowing the teens or children to explore feelings and events in a safe environment.
Cognitive therapy aims to change harmful ways of thinking and reframe negative thoughts in a more positive way. Aims of cognitive therapy include various steps of patient learning. They learn to monitor their negative thoughts, to become aware of the link between their thoughts, the affect their thoughts have on them & their behavior, to become aware of and change the negative, depressive thoughts which affect their health and state of mind 
Behavioral therapy helps change harmful ways of acting and gain control over behavior which is causing problems.
Interpersonal therapy helps one learn to relate better with others, express feelings, and develop better social skills.
The principles of group dynamics are relevant to family therapists who must not only work with individuals, but with entire family systems. Two key concepts that influence family therapy are the distinction between the process and content of group discussions, and role theory.
Therapists strive to understand not just what the group members say, but how these ideas are communicated (process). Therapists can help families improve the way they relate and thus enhance their own capacity to deal with the content of their problems by focusing on the process of their discussions. Virginia Satir expanded on the concept of how individuals behave and communicate in groups by describing several family roles that can serve to stabilize expected characteristic behavior patterns in a family. For instance, if one child is considered to be a "rebel child", a sibling may take on the role of the "good child" to alleviate some of the stress in the family. This concept of role reciprocity is helpful in understanding family dynamics because the complementary nature of roles makes behaviors more resistant to change.
Throughout the development and research of this disorder, controversies have emerged over the legitimacy of depression in childhood and adolescence as a diagnosis, the proper measurement and validity of scales to diagnose, and the safety of particular treatments.
Legitimacy as a diagnosisEdit
In early research of depression in children, there was debate as to whether or not children could clinically fit the criteria for major depressive disorder. However, since the 1970s, it has been accepted among the psychological community that depression in children can be clinically significant. The more pertinent controversy in psychology today centers around the clinical significance of subthreshold mood disorders. This controversy stems from the debate regarding the definition of the specific criteria for a clinically significant depressed mood in relation to the cognitive and behavioral symptoms. Some psychologists argue that the effects of mood disorders in children and adolescents that exist (but do not fully meet the criteria for depression) do not have severe enough risks.[clarification needed] Children in this area of severity, they argue, should receive some sort of treatment since the effects could still be severe. However, since there has yet to be enough research or scientific evidence to support that children that fall within the area just shy of a clinical diagnosis require treatment, other psychologists are hesitant to support the dispensation of treatment.
In order to diagnose a child with depression, different screening measures and reports have been developed to help clinicians make a proper decision. However, the accuracy and effectiveness of certain measures that help psychologists diagnose children have come into question. Questions have also surfaced about the safety and effectiveness of antidepressant medications.
The effectiveness of dimensional child self-report checklists has been criticized. Although literature has documented strong psychometric properties, other studies have shown a poor specificity at the top end of scales, resulting in most children with high scores not meeting the diagnostic criteria for depression. Another issue with reliability of measurement for diagnosis occurs in parent, teacher, and child reports. One study, which observed the similarities between child self-report and parent reports on the child's symptoms of depression, acknowledged that on more subjective symptom reports measures, the agreement was not significant enough to be considered reliable. Two self-report scales demonstrated an erroneous classification of 25% of children in both the depressed and controlled samples. A large concern in the use of self-report scales is the accuracy of the information collected. The main controversy is caused by uncertainty about how the data from these multiple informants can or should be combined to determine whether a child can be diagnosed with depression.
The controversy over the use of antidepressants began in 2003 when Great Britain's Department of Health stated that, based on data collected by the Medicines and Healthcare products Regulatory Agency, paroxetine (an antidepressant) should not be used on patients under the age of 18. Since then, the United States Food and Drug Administration (FDA) has issued a warning describing the increased risk of adverse effects of antidepressants used as treatment in those under the age of 18. The main concern is whether the risks outweigh the benefits of the treatment. In order to decide this, studies often look at the adverse effects caused by the medication in comparison to the overall symptom improvement. While multiple studies have shown an improvement or efficacy rate of over 50%, the concern of severe side effects – such as suicidal ideation or suicidal attempts, worsening of symptoms, or increase in hostility – are still concerns when using antidepressants. However, an analysis of multiple studies argues that while the risk of suicidal ideation or attempt is present, the benefits significantly outweigh the risks. Due to the variability of these studies, it is currently recommended that if antidepressants are chosen as a method of treatment for children or adolescents, the clinician monitor closely for adverse symptoms, since there is still no definitive answer on the safety and overall efficacy.
- Birmaher B., Ryan N.D., Williamson D.E., Brent D.A., Kaufman J., Dahl R.E., Perel J., Nelson B. (1996). "Childhood and adolescent depression: A review of the past 10 years. Part I.". Journal of the American Academy of Child and Adolescent Psychiatry. 35 (11): 1427–1439. doi:10.1097/00004583-199611000-00011. PMID 8936909.CS1 maint: multiple names: authors list (link)
- American Academy of Child & Adolescent Psychiatry. The Depressed Child, "Facts for Families," No. 4 (5/08)
- Eapen Valsamma (2012). "Strategies and challenges in the management of adolescent depression". Current Opinion in Psychiatry. 25 (1): 7–13. doi:10.1097/yco.0b013e32834de3bd. PMID 22156932.
- - The Association for University and College ... - AUCCCD. www.aucccd.org/assets/documents/aucccd 2016 monograph - public.pdf.
- Kovacs M.; Feinberg T.L.; Crousenovak M.A.; Paulauskas S.L.; Finkelstein R. (1984). "Depressive-disorders in childhood. 1. A longitudinal prospective-study of characteristics and recovery". Archives of General Psychiatry. 41 (3): 229–237. doi:10.1001/archpsyc.1984.01790140019002.
- Kessler R.C., Avenevoli S., Merikangas K.R. (2001). "Mood disorders in children and adolescents: An epidemiological perspective". Biological Psychiatry. 49 (12): 1002–1014. doi:10.1016/s0006-3223(01)01129-5.CS1 maint: multiple names: authors list (link)
- Hankin B.L., Abramson L.Y., Moffitt T.E., Siilva P.A., McGee R. Angell (1998). "Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study". Journal of Abnormal Psychology. 107 (1): 128–1140. doi:10.1037/0021-843x.107.1.128.CS1 maint: multiple names: authors list (link)
- Nolen-hoeksema S., Girgus J.S. (1994). "The emergence of gender differences in depression during adolescence". Psychological Bulletin. 115 (3): 424–443. doi:10.1037/0033-2909.115.3.424.
- Shaffer D, Gould MS, Fisher P, et al. (1996). "Psychiatric diagnosis in child and adolescent suicide". Archives of General Psychiatry. 53 (4): 339–48. doi:10.1001/archpsyc.1996.01830040075012. PMID 8634012.
- Hallfors Denise D.; et al. (2004). "Adolescent depression and suicide risk: association with sex and drug behavior". American Journal of Preventive Medicine. 27 (3): 224–231. doi:10.1016/s0749-3797(04)00124-2.
- Shaffer D, Craft L. Methods of adolescent suicide prevention" Journal of Clinical Psychiatry 1999; 60(Suppl 2): 70-4; discussion 75-6, 113-6.
- Weissman MM, Wolk S, Goldstein RB, et al. (1999). "Depressed adolescents grown up". Journal of the American Medical Association. 281 (18): 1707–13. doi:10.1001/jama.281.18.1707.
- Lopez Molina, Mariane Acosta; Jansen, Karen; Drews, Cláudio; Pinheiro, Ricardo; Silva, Ricardo; Souza, Luciano (7 May 2013). "Major depressive disorder symptoms in male and female young adults". Psychology, Health & Medicine. 19 (2): 136–145. doi:10.1080/13548506.2013.793369.
- Calvete, Esther; Cardeñoso, Olga (2005-04-01). "Gender Differences in Cognitive Vulnerability to Depression and Behavior Problems in Adolescents". Journal of Abnormal Child Psychology. 33 (2): 179–192. doi:10.1007/s10802-005-1826-y. ISSN 0091-0627.
- Klomek Anat Brunstein; et al. (2007). "Bullying, depression, and suicidality in adolescents". Journal of the American Academy of Child & Adolescent Psychiatry. 46 (1): 40–49. doi:10.1097/01.chi.0000242237.84925.18. PMID 17195728.
- Psujek, Jessica K.; Martz, Denise M.; Curtin, Lisa; Michael, Kurt D.; Aeschleman, Stanley R. (2004-02-01). "Gender differences in the association among nicotine dependence, body image, depression, and anxiety within a college population". Addictive Behaviors. 29 (2): 375–380. doi:10.1016/j.addbeh.2003.08.031.
- Hallfors Denise D.; et al. (2004). "Adolescent depression and suicide risk: association with sex and drug behavior". American Journal of Preventive Medicine. 27 (3): 224–231. doi:10.1016/s0749-3797(04)00124-2.
- "A Fact Sheet". National Institute of Mental Health.
- Angold A., Costello E.J. (1993). "Depressive co-morbidity in children and adolescents: Empirical, theoretical, and methodological issues". The American Journal of Psychiatry. 150 (12): 1779–1791. CiteSeerX 10.1.1.475.1415. doi:10.1176/ajp.150.12.1779. PMID 8238631.
- Brady E.U., Kendall P.C. (1992). "Co-morbidity of anxiety and depression in children and adolescents". Psychological Bulletin. 111 (2): 244–255. doi:10.1037/0033-2909.111.2.244.
- Kovacs M., Paulauskas S., Gatsonis C., Richards C. (1988). "Depressive-disorders in childhood. 3. A longitudinal-study of co-morbidity with and risk for conduct disorders". Journal of Affective Disorders. 15 (3): 205–217. doi:10.1016/0165-0327(88)90018-3.CS1 maint: multiple names: authors list (link)
- Weller, Bridget E.; Blanford, Kathryn L.; Butler, Ashley M. (2018). "Estimated Prevalence of Psychiatric Comorbidities in U.S. Adolescents With Depression by Race/Ethnicity, 2011-2012". The Journal of Adolescent Health. 62 (6): 716–721. doi:10.1016/j.jadohealth.2017.12.020. ISSN 1879-1972. PMID 29784115.
- Sutton, Amy, ed. (2012). "Depression in Children and Adolescents". Depression Sourcebook, 3rd Edition. Detroit: Omnigraphics: Health Reference Series. pp. 131–143.
- Richardson, LP; Davis, R; Poulton, R; McCauley, E; Moffitt, TE; Caspi, A; Connell, F (Aug 2003). "A longitudinal evaluation of adolescent depression and adult obesity". Arch Pediatr Adolesc Med. 157 (8): 739–45. doi:10.1001/archpedi.157.8.739. PMID 12912778.
- Carney RM, et al. (15 May 2013). "Depression in kids linked to cardiac risks in teens". Science Daily. Retrieved 4 July 2014.
- Kaufman J., Martin A., King R.A., Charney D. (2001). "Are child-, adolescent-, and adult-onset depression one and the same disorder?". Biological Psychiatry. 49 (12): 980–1001. doi:10.1016/s0006-3223(01)01127-1.CS1 maint: multiple names: authors list (link)
- Zahn-Waxler C., Klimes-Dougan B., Slattery M.J. (2000). "Internalizing problems of childhood and adolescence: Prospects, pitfalls, and progress in understanding the development of anxiety and depression". Development and Psychopathology. 12 (3): 443–466. doi:10.1017/s0954579400003102.CS1 maint: multiple names: authors list (link)
- Hynes, J; N. McCune (2002). "Follow-up of childhood depression: historical factors". British Journal of Psychiatry. 181 (2): 166–167. doi:10.1192/bjp.181.2.166. PMID 12151295.
- Kovacs M (1985). "The Children's Depression Inventory (CDI)". Psychopharmacol Bull. 21 (4): 995–8. PMID 4089116.
- "Final Update Summary: Depression in Children and Adolescents: Screening - US Preventive Services Task Force". www.uspreventiveservicestaskforce.org. Retrieved 2016-03-30.
- Bradley K.L., McGrath P.J., Brannen C.L., Bagnell A.L. (2010). "Adolescents' attitudes and opinions about depression treatment". Community Mental Health Journal. 46 (3): 242–251. doi:10.1007/s10597-009-9224-5. PMID 19636707.CS1 maint: multiple names: authors list (link)
- Chakraburtty, Amal. "Depression in Children". WebMD. WebMD, LLC. Retrieved 15 September 2011.
- Jorm AF, Allen NB, O'Donnell CP, Parslow RA, Purcell R, Morgan AJ (October 2006). "Effectiveness of complementary and self-help treatments for depression in children and adolescents". Med. J. Aust. 185 (7): 368–72. PMID 17014404.
- Weisz J.R., Thurber C.A., Sweeney L., Proffitt V.D., LeGagnoux G.L. (1997). "Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training". Journal of Consulting and Clinical Psychology. 65 (4): 703–707. doi:10.1037/0022-006x.65.4.703.CS1 maint: multiple names: authors list (link)
- "An overview of talk therapy". Archived from the original on 2013-02-18. Retrieved 2012-07-25.
- Danielsson, Ulla E.; Bengs, Carita; Samuelsson, Eva; Johansson, Eva E. (2010-12-13). ""My Greatest Dream is to be Normal": The Impact of Gender on the Depression Narratives of Young Swedish Men and Women". Qualitative Health Research. 21 (5): 612–24. doi:10.1177/1049732310391272. ISSN 1049-7323. PMID 21149850.
- Aaron T Beck, 1979, Cognitive Therapy of Depression , Guilford Press.
- Nichols & Schwartz, Family Therapy: Concepts and Methods. Fourth Edition. Allyn & Bacon 1998
- "Family therapy historical overview". Archived from the original on 2007-06-07. Retrieved 2012-07-25.
- Chambers W.J., Puigantich J., Tabrizi M., Davies M. (1982). "Psychotic symptoms in prepubertal major depressive disorder". Archives of General Psychiatry. 39 (8): 921–927. doi:10.1001/archpsyc.1982.04290080037006.CS1 maint: multiple names: authors list (link)
- Barret M.L., Berney T.P., Bhate S., Famuyiwa O.O., Fundudis T., Kolvin I., Tyrer S. (1991). "Diagnosing childhood depression - who should be interviewed - parent or child - the Newcastle-child-depression-project". British Journal of Psychiatry. 159 (11): 22–27. doi:10.1192/S0007125000292118. PMID 1840754.CS1 maint: multiple names: authors list (link)
- Cheung A.H., Emslie G.J., Mayes T.L. (2005). "review of the efficacy and safety and antidepressants in youth depression". Journal of Child Psychology and Psychiatry. 46 (7): 735–754. doi:10.1111/j.1469-7610.2005.01467.x. PMID 15972068.CS1 maint: multiple names: authors list (link)
- Fundudis T., Berney T.P., Kolvin I., Famuyiwa O.O., Barrett L., Bhate S., Tyrer S.P. (1991). "Reliability and validity of 2 self-rating scales in the assessment of childhood depression". British Journal of Psychology. 159 (11): 36–40. doi:10.1192/S0007125000292131. PMID 1840756.CS1 maint: multiple names: authors list (link)
- Bridge J.A., Iyengar S., Salary C.B., Barbe R.P., Birmaher B., Pincus H.A., Ren L., Brent D.A. (2007). "Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials". Journal of the American Medical Association. 297 (15): 1683–1696. doi:10.1001/jama.297.15.1683. PMID 17440145.CS1 maint: multiple names: authors list (link)