Treatment Options for Psychotic Depression in Adolescents: A Comprehensive Review.

Abstract

Despite being associated with increased illness severity and suicidality compared to non-psychotic depression, psychotic depression remains under-researched, particularly in adolescents. With this article, we aim to review treatment options for psychotic depression in adolescents. We performed a multi-step narrative review, first identifying studies on adolescents with psychotic depression evaluating any intervention and with any methodological design. We subsequently complemented our search with systematic reviews and meta-analysis evaluating treatment interventions in adults with psychotic depression and adolescents with bipolar depression. Finally, we reviewed clinical guidelines to complement the evidence found and provided recommendations for clinical practice. Based on the findings, we recommend a stepped approach to the treatment of psychotic depression in adolescents. For mild cases with predominance of depressive symptoms, antidepressant monotherapy with a serotonin selective reuptake inhibitor (eg fluoxetine, sertraline or citalopram) could be trialed first. In severe presentations, antidepressant-antipsychotic combination would be the treatment of choice. The antidepressant-antipsychotic combination has been recommended by several clinical guidelines, systematic reviews and meta-analysis in this population, adolescents with bipolar depression and adults with psychotic depression. Another combination of antidepressant-antipsychotic with evidence from a case report is the fluoxetine-quetiapine combination. For those adolescents not responding to the antidepressant-antipsychotic combination, or those requiring a rapid response or unable to take medication, electroconvulsive therapy could be considered. Psychological interventions (eg cognitive behavioral therapy, family therapy or interpersonal psychotherapy training for adolescents) are recommended by clinical guidelines but require further research. Overall, literature on the field is scarce and limited, with most evidence coming from adults and other populations. Further research into effective and safe treatment of psychotic depression in adolescent population is needed.