Childhood and Adolescent Depression
SHASHI K. BHATIA, M.D., and SUBHASH C. BHATIA, M.D., Creighton University, Department of Psychiatry, Omaha, Nebraska
(abstract)….Juvenile depression may manifest in different forms….children younger than seven years may not be able to describe their internal mood state and may express their distress through vague somatic symptoms or pain. Irritable mood may be the cause of angry, hostile behavior. Impaired attention, poor concentration, and anxiety may resemble attention-deficit/hyperactivity disorder, and substance abuse may be a means of self-medication for depression.
Diagnosis of primary depressive mood disorders (Table 2) requires that physicians rule out depression from medical causes, such as endocrinopathies, malignancies, chronic diseases, infectious mononucleosis, anemia, and vitamin deficiency (especially folic acid),10 and from medications, such as isotretinoin (Accutane).13 If any of these causes are present, the condition is referred to as secondary depressive mood disorder or depressive mood disorder secondary to medical conditions. Lack of improvement following treatment or medication discontinuation warrants further evaluation and treatment.
|TABLE 2Key Clinical Decision Points for Depressive Disorders|
|Is this depression caused by a general medical condition, a medication, or both?||Rule out other causes of depressive mood disorders.|
|Is this depression related to drug or alcohol abuse?||Determine whether secondary to or complicated by substance abuse.|
|Is this depression related to a reaction to a stressful life event?||Consider a diagnosis of adjustment disorder.|
|Is this a chronic, mild depression?||Consider dysthymic disorder.|
|Is this another type of depressive disorder?||Consider minor depression, bipolar depression, depression caused by seasonal affective disorder, or atypical depression.|
|Is this major depression?||Apply DSM-IV criteria (see Table 3). Assess for severity and psychotic features.|
|Is there a coexisting mental illness?||Dysthymic disorder, anxiety disorders, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and substance use disorder are common comorbidities.|
|Is this a dangerous depression?||Perform suicide risk assessment.|
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
Major depressive disorder is the most severe of the depressive mood disorders. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., criteria for diagnosing major depressive disorder in children and adolescents are similar to those for adults (Table 3).20-24
|TABLE 3Criteria for Major Depressive Episode in Adults, Children, and Adolescents|
|Adults||Children and adolescents|
|A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.|
(1) Depressed mood most of the day, nearly every day, as indicated by subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
|Mood can be depressed or irritable. Children with immature cognitive-linguistic development may not be able to describe inner mood states and therefore may present with vague physical complaints, sad facial expression, or poor eye contact. Irritable mood may appear as “acting out”; reckless behavior; or hostile, angry interactions. Adult-like mood disturbance may occur in older adolescents.|
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation made by others)
|Loss of interest can be in peer play or school activities.|
(3) Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day
|Children may fail to make expected weight gain rather than losing weight.|
(4) Insomnia or hypersomnia nearly every day
|Similar to adults|
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feeling of restlessness or being slowed down)
|Concomitant with mood change, hyperactive behavior may be observed.|
(6) Fatigue or loss of energy nearly every day
|Disengagement from peer play, school refusal, or frequent school absences may be symptoms of fatigue.|
(7) Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
|Child may present with self-depreciation (e.g., “I’m stupid,” “I’m a retard”). Delusional guilt usually is not present.|
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (by subjective account or as observed by others)
|Problems with attention and concentration may be apparent as behavioral difficulties or poor performance in school.|
(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
|There may be additional nonverbal cues for potentially suicidal behavior, such as giving away a favorite collection of music or stamps.|
|B. Symptoms do not meet the criteria for mixed bipolar disorder.||Same as adults|
|C. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.||Clinically significant impairment of social or school functioning is present. Adolescents also may have occupational dysfunction.|
|D. Symptoms are not caused by the direct physiologic effects of a substance (e.g., drug of abuse, medication) or a general medical condition (e.g., hypothyroidism).||Similar to adults|
|E. Symptoms are not caused by bereavement-i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.||Psychotic symptoms in severe major depression, if present, are more often auditory hallucinations (usually criticizing the patient) than delusions.|
Adapted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. rev. Washington, D.C.: American Psychiatric Association, 2000:356, with additional information from references 21 through 24.
If substance abuse is present, an independent diagnosis of major depression requires the presence of depression before substance abuse or during periods of remission. Concurrent treatment of substance use disorder and depression is needed to improve outcomes for both.25
Adjustment disorder with depressed mood is the most common depressive mood disorder in children and adolescents. Symptoms start within three months of an identifiable stressor (e.g., loss of a relationship), with distress in excess of what would be expected and interference with social, occupational, or school functioning. Symptoms should not meet criteria for another psychiatric disorder, are not caused by bereavement, and do not last longer than six months after the stressor has stopped.
Dysthymic disorder is a chronic, milder form of depression characterized by a depressed or irritable mood (indicated subjectively or described by others) present for more days than not for at least one year (as opposed to two years for adults). Two of the following additional symptoms also are required: changes in appetite, sleep difficulty, fatigue, low self-esteem, poor concentration or difficulty with making decisions, and feelings of hopelessness.20 About 70 percent of children and adolescents with dysthymic disorder eventually develop major depression.26
Diagnosis of minor depression requires the presence of two out of the nine symptoms for major depression (Table 3), one being depressed mood or decreased interest, and a time course similar to that of major depression. If present between the episodes of major depression, minor depression can be a risk factor for relapse.20
Atypical depression is characterized by hypersomnia, increased appetite with carbohydrate craving, weight gain, interpersonal rejection sensitivity, feeling of heaviness in the arms and legs, and reactivity of mood.20 It is relatively common in children and adolescents.27
Presence of depressed mood, increased sleep, decreased appetite, and social isolation between October and February of two consecutive years suggests seasonal affective disorder.
Although less common, bipolar disorder is an important differential diagnosis. In 40 percent of children and adolescents with bipolar disorder, the illness begins with a major depressive episode.2 Risk factors for bipolar disorder are acute and early onset of depression, presence of psychotic symptoms (e.g., hallucinations), significant psychomotor slowing, family history of bipolar disorder, any mood disorder in three consecutive generations of family members, and antidepressant-induced mania.28 Physicians should maintain a higher level of surveillance in patients at greater risk of bipolar disorder.
In severe major depression with psychosis, auditory hallucinations (often criticizing the patient) rather than delusions (as occur in adults) are present. This age-related variability in psychotic symptoms may be a result of differences in cognitive maturation. Treatment of major depressive disorder with psychosis requires the combination of an antidepressant and an antipsychotic medication.29 Patients with this disorder are at a greater risk of suicide and often require inpatient psychiatric admission.
Suicide Risk Assessment
During the first visit, physicians should assess the suicide risk of patients with depression and decide on the most appropriate treatment venue. Depressive disorders are the most common diagnoses present in all suicides. Twenty percent of teenagers seriously contemplate suicide,30 and 8 percent attempt it.31 In 2001, there were 1,833 suicides in children and adolescents 10 to 18 years of age; and in 2000, suicide was the third leading cause of death among those 10 to 19 years of age.31
Suicidal communication in any form must be taken seriously. Documentation of suicide risk should include high-risk and protective factors for suicide (Table 4).1,30-36 Patients with multiple high-risk factors should be referred to a child and adolescent psychiatrist. However, patients with low-risk and protective factors (e.g., a close, warm, supportive family; religious beliefs against suicide; a positive future outlook) are less likely to harm themselves32 and may be treated as outpatients.
|TABLE 4Risk Factors and Protective Factors for Suicide in Children and Adolescents|
|High-risk factors||Protective or low-risk factors|
|Age: late teens through early 20s32; 20 percent of teenagers contemplate suicide,30 and 8 percent attempt it.31Sex: ideation and attempts more common in females32; completed suicides five times more common in males.32Ethnicity: teenage suicides are more common in whites and Hispanics than in blacks; rates are highest in Native American teens and lowest in Asian teens and those from the Pacific islands.||Black female child|
|Major depression: increases the risk of suicide 12-fold for both sexes,1 especially if hopelessness is a symptomSubstance abuse: increases the risk of suicide1 about twofoldConduct disorder: linked to one third of suicides in adolescent boys1 and increases overall risk twofold1Current stressors or losses (e.g., trouble in school or with the law, loss of romantic relationship, unwanted pregnancy, intense humiliation)33
Physical or sexual abuse32
Minimal communication with parents34
|No current depressionNo current alcohol or substance abuseGood problem-solving and coping skillsNo current stressors or losses
No history of physical or sexual abuse
Close supportive family relationships and good communications with parents
Availability of parental support and close supervision during stressful life event
Strong religious belief or faith
Positive, hopeful outlook about future with specific positive and concrete plans and goals
Ability to articulate reasons to live
Ambivalence about suicide
|History of suicidal behavior|
|Suicidal thoughts with plan: specific plans for suicide and the means to carry it out, including nonverbal suicidal behaviors (e.g., giving away valued possessions or collections)Previous suicide attempt: one of the strongest predictors of completed suicide1Family history of suicide and depression35,36Availability of firearms or toxic substances||No active suicidal thoughts or intent; no nonverbal suicidal behaviorsNo history of suicide attemptNo family history of suicideNo access to firearms or toxic substances|
|Media coverage of suicide: imitation plays a part in suicidal behavior, often following intense media coverage of a celebrity suicide or a string of suicides in school.32|
|SORT: KEY RECOMMENDATIONS FOR PRACTICE|
|Clinical recommendation||Evidence rating||References|
|Tricyclic antidepressants should not be used to treat childhood or adolescent depression.||A||18, 40, 41|
|Selective serotonin reuptake inhibitors have limited evidence of effectiveness in children
and adolescents and should be reserved for treatment of severe major depression.
|Cognitive behavior therapy is effective for the treatment of mild to moderate depression.||A||18, 37-39|
|Children and adolescents taking antidepressants should be monitored closely for suicidal thoughts and behavior.||C||53|
|Depression should be treated for a minimum of six months.||C||29|
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 13 or http://www.aafp.org/afpsort.xml.