Depression in Children and Adolescents

Background

• Major depressive disorder (MDD) is characterized by persistent low mood, lack of positive affect, and loss of interest in usually pleasurable activities (anhedonia) that is different from patient's usual self and causes significant distress or impairment for ≥ 2 weeks.
• Major depressive disorder (MDD) has a heterogeneous clinical presentation such that 2 patients with the diagnosis may have only a few symptoms in common.
• The prevalence of major depressive disorder is reported to be about 2% in children aged < 13 years and 4%-8% in adolescents, Subsyndromal depressive symptoms may be present in 5%-10% of children and adolescents.
• Some patients have specific subtypes of depression, which may be clinically useful for predicting outcomes and choosing treatment. They include:
  • melancholic depression (melancholia)
  • depression with atypical features
  • depression with psychotic features
  • depression with catatonic features
  • depression with anxious distress
• MDD classification by episode (first or recurrent), status (such as partial or full remission) and severity is relevant to treatment. Severity classifications include:
  • Mild MDD is present if the minimum number of symptoms are present, symptoms are distressing but manageable, and functional impairment is minor
  • Moderate MDD falls between mild and severe
  • Severe MDD is present if there is suicidal ideation, a substantial excess of required symptoms present, symptoms are unmanageable for the patient, and disability in responsibilities is apparent
• Risk factors for depression in children and adolescents are similar to those in adults, but also include bullying, pubertal hormonal changes, maternal age < 18 years, and trauma or adverse childhood experiences.
• Compared to adults with depression, the prognosis in young patients is more variable - some may have family history and high risk for recurrence, others may develop bipolar disorder; still others may develop behavior or substance abuse problems rather than recurring depression. An estimated 2% of children and adolescents with depression develop bipolar disorder within 4 years; 60%-90% of patients remit within 1 year. Recurrence risk is reported to be 20%-60% 1-2 years after remission.
• Depression screening recommendations for pediatric patients vary among organizations, but American guidelines typically recommend annual screening for adolescents aged ≥ 12 years in clinical practices that have systems in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up (Strong Recommendation). Screening instruments that may be helpful for screening in children and adolescents include the Patient Health Questionnaire 2 (PHQ-2), the PHQ-9, and the PHQ modified for adolescents.
• Identify and promptly treat or refer patients who exhibit suicidal ideation.

Evaluation

• Major depressive disorder (MDD) is a clinical diagnosis based on the presence of a depressed mood or anhedonia and associated symptoms, usually defined by either Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD-10 criteria after the exclusion of other causes.
• A complete history and physical should be performed to exclude other causes of symptoms as well as to assess for psychosocial stressors such as abuse or neglect, substance abuse, medication side effects, past or current suicidal attempts or ideation, and family or personal history of psychiatric illness (Strong Recommendation).
• Relevant ethnic and cultural conditions should be considered as they may influence presentation, interpretation, or description of depressive symptomatology (Strong Recommendation).
• Children have a similar clinical presentation as adults with depression but some features may be altered due to the stage of the patient in terms of cognitive, social, emotional, and physical development. Younger patients typically have fewer melancholic symptoms, delusions, and suicide attempts compared to adults.
• Children and adolescents may not be able or willing to verbalize feelings of depression, but may present with complaints or observable manifestations.
  • Children aged 3-5 years may present with difficulty verbalizing feelings, decreased interest in play, self-destructive themes in play, and/or thoughts of suicide or worthlessness.
  • Children aged 6-8 years may present with difficulty verbalizing feelings, increased somatic complaints, crying or shouting outbursts, unexplained irritability, and observed anhedonia.
  • Children aged 9-12 years may present with low self-esteem, guilt, hopelessness, increased boredom, feelings of wanting to run away, and fear of death.
  • General manifestations of depression in children may include
    • mood lability
    • irritability
    • low frustration tolerance
    • temper tantrums
    • somatic complaints (for example, abdominal pain)
    • social withdrawal
    • restlessness, separation anxiety, phobias, and/or hallucinations
• Adolescents and young adults (ages 13-18 years) may have fluctuating symptoms which include:
  • unexplained physical symptoms (for example, abdominal pain)
  • irritability and/or mood reactivity
  • anhedonia
  • boredom
  • hypersomnia
  • hopelessness
  • weight changes (including not reaching developmental milestones)
  • substance use
  • suicide attempts
  • behavioral problems including refusal to attend school
  • eating disorders
• Patients diagnosed with MDD should have careful and ongoing evaluation of suicide risk (Strong Recommendation).

Management

• Hospitalization should be considered for patients who pose a serious threat of harm to self or others (Strong Recommendation).
• Treatment of depression should include confidential relationship with patient plus collaborative relationships with parents/caregivers, medical providers, appropriate school personnel, and other mental health professionals (Strong Recommendation).
• Educate patient and family members about causes, symptoms, course and treatment options for depression, and provide supportive treatment with family and school involvement (Strong Recommendation).
• Combination of education, supportive treatment, and case management without pharmacotherapy for 6-8 weeks appears to be sufficient treatment for children and adolescents with uncomplicated or brief depression or mild psychosocial impairment (Strong Recommendation).
• If the patient does not respond to supportive treatment or if depression is more complicated, offer psychotherapy and/or antidepressants (Strong Recommendation).
  • Psychotherapy modalities with evidence for efficacy include cognitive behavioral therapy or interpersonal therapy for adolescents.
  • Fluoxetine and escitalopram are recommended first-line antidepressant options for children and adolescents and are FDA-approved. Other selective serotonin reuptake inhibitors that are also recommended options for pediatric patients, but may not be FDA-approved for use include sertraline, citalopram, and fluvoxamine.
• Children and adolescents on antidepressant medication should have careful monitoring for adverse events. Evidence showing short-term increased risk of suicidal ideation and behavior in adolescents taking SSRIs has led to a FDA Black Box warning on antidepressants.
• Continuation or maintenance treatment with antidepressants may reduce risk of relapse in children and adolescents with depressive disorder.
  • Treatment should continue for ≥ 6-12 months with frequent follow-up contacts, allowing for sufficient time to monitor clinical status, environmental conditions, and (if applicable) medication side effects (Strong Recommendation).
  • Regular assessments of patients in remission should continue for up to 1 year after treatment, and for up to 2 years in patients with a high risk for recurrence (Strong Recommendation).
• Treatment for depression includes management of comorbid conditions (Strong Recommendation) and parallel treatment of the caregiver if a psychiatric disorder is present.
• Patients with depression plus psychotic features, seasonal onset, or bipolar disorder require specific management of those conditions (Strong Recommendation).
• Electroconvulsive therapy (ECT) should be considered in adolescents aged ≥ 12 years with severe, persistent, and potentially life-threatening depression who are unresponsive to other treatments (Strong Recommendation).
• Transcranial magnetic stimulation is reported to be potentially be helpful in some adolescents with treatment-resistant depression.