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Intervenções para prevenir a recaída e a recorrência da perturbação depressiva em crianças e adolescentes.

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Background

Depressive disorders often begin during childhood or adolescence. There is a growing body of evidence supporting effective treatments during the acute phase of a depressive disorder. However, little is known about treatments for preventing relapse or recurrence of depression once an individual has achieved remission or recovery from their symptoms.

Objectives

To determine the efficacy of early interventions, including psychological and pharmacological interventions, to prevent relapse or recurrence of depressive disorders in children and adolescents.

Search methods

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 1 June 2011). The CCDANCTR contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). In addition we handsearched the references of all included studies and review articles.

Selection criteria

Randomised controlled trials using a psychological or pharmacological intervention, with the aim of preventing relapse or recurrence from an episode of major depressive disorder (MDD) or dysthymic disorder (DD) in children and adolescents were included. Participants were required to have been diagnosed with MDD or DD according to DSM or ICD criteria, using a standardised and validated assessment tool.

Data collection and analysis

Two review authors independently assessed all trials for inclusion in the review, extracted trial and outcome data, and assessed trial quality. Results for dichotomous outcomes are expressed as odds ratio and continuous measures as mean difference or standardised mean difference. We combined results using random‐effects meta‐analyses, with 95% confidence intervals. We contacted lead authors of included trials and requested additional data where possible.

Main results

Nine trials with 882 participants were included in the review. In five trials the outcome assessors were blind to the participants' intervention condition and in the remainder of trials it was unclear. In the majority of trials, participants were either not blind to their intervention condition, or it was unclear whether they were or not. Allocation concealment was also unclear in the majority of trials. Although all trials treated participants in an outpatient setting, the designs implemented in trials was diverse, which limits the generalisability of the results. Three trials indicated participants treated with antidepressant medication had lower relapse‐recurrence rates (40.9%) compared to those treated with placebo (66.6%) during a relapse prevention phase (odds ratio (OR) 0.34; 95% confidence interval (CI) 0.18 to 0.64, P = 0.02). One trial that compared a combination of psychological therapy and medication to medication alone favoured a combination approach over medication alone, however this result did not reach statistical significance (OR 0.26; 95% CI 0.06 to 1.15). The majority of trials that involved antidepressant medication reported adverse events including suicide‐related behaviours. However, there were not enough data to show which treatment approach results in the most favourable adverse event profile.

Authors' conclusions

Currently, there is little evidence to conclude which type of treatment approach is most effective in preventing relapse or recurrence of depressive episodes in children and adolescents. Limited trials found that antidepressant medication reduces the chance of relapse‐recurrence in the future, however, there is considerable diversity in the design of trials, making it difficult to compare outcomes across studies. Some of the research involving psychological therapies is encouraging, however at present more trials with larger sample sizes need to be conducted in order to explore this treatment approach further.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Tratamentos para prevenir a recorrência da depressão em crianças e adolescentes.

Muitas crianças e adolescentes diagnosticados com perturbação depressiva vão experienciar uma recaída ou recorrência dos seus sintomas. Pouco é conhecido acerca de qual a abordagem terapêutica que melhor funciona a prevenir a ocorrência disto, uma vez a criança ou adolescente tendo incialmente remitido ou recuperado de um episódio depressivo. Esta revisão visou determinar a eficácia de intervenções precoces, incluindo psicológicas, sociais e farmacológicas a prevenir a recaída ou recorrência de perturbações depressivas em crianças e adolescentes. Esta revisão incluiu nove estudos que avaliaram a eficácia da medicação antidepressiva e terapias psicológicas na redução do risco de um episódio depressivo futuro em crianças e adolescentes. Os ensaios variaram na sua qualidade e desenho metodológico, limitando conclusões que pudessem ser extraídas dos resultados. No geral, esta revisão descobriu que a medicação antidepressiva reduz a probabilidade de crianças e adolescentes experienciarem outro episódio de depressão, comparada com um comprimido de placebo. Terapias psicológicas também parecem promissoras como tratamento para prevenir futuros episódios depressivos, embora dados os assuntos acima mencionados no que concerne à qualidade e ao desenho do ensaios, juntamente com o pequeno número de ensaios incluídos nesta revisão, não é claro quão eficazes estas terapias são no presente.