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Childhood Depression
Aka: Childhood Depression, Depression in Children, Pediatric Depression, Adolescent Depression, Major Depression in Children
- See Also
- Major Depression
- Epidemiology
- Major DepressionIncidence has increased in the last decade
- 2005: Major Depression episode in last year occurred in 9%
- 2014: Major Depression episode in last year occurred in 11%
- 2016: Major Depression episode in last year occurred in 13%
- From 5% in 12 year olds to 17% in 17 year olds
- Gender predominance
- Boys are slightly more likely than girls to have Major Depression before age 12 years old
- Girls are up to twice as likely as boys to experience Major Depression after Puberty
- Precautions
- Missed or incorrect diagnosis occurs in up to 70%
- Major Depression is treated in only 40% of cases that effect children and teens
- Despite 70% experiencing significant Impairment from their Major Depression
- Pitfalls in diagnosis
- Atypical presentations: Headaches, Stomache pain
- Downplayed symptoms if parents are also depressed
- Risk factors
- Comorbid illness (e.g. Diabetes Mellitus, Asthma)
- Puberty-related hormonal changes (esp. early Puberty)
- Family History of Major Depression
- Medications: Accutane
- Tobacco Abuse or Marijuana use
- Attention Deficit Disorder
- High functioning Autism
- LGBTQ
- Obesity
- Emotional stressors or social factors
- Poor family functioning or parental rejection
- Relationship break-ups or loss of loved one
- Video game addiction
- Social media problematic use
- Decreased parent and peer attachment
- Victim of Bullying, Violence, physical, sexual or emotional abuse (see Child Abuse)
- Inadequate Physical Activity
- Natural disasters
- Screening
- See Depression Screening Tools
- USPTF, AAFP and AAP all recommend Major Depression screening in age 12-18 years
- Ages 7 to 17 years old
- Childrens Depression Inventory (CDI)
- Ages 8 to 12 years old
- Reynolds Child Depression Scale
- Ages 13 to 18 years old
- Reynolds Adolescent Depression Scale
- Ages 13 and older
- Obtain Patient Health Questionnaire-2 (PHQ-2) each year at routine visit
- Patient Health Questionnaire-9 (PHQ-9) or PHQ-A (modified for ages to 11 to 17 years old)
- Ages 14 and older
- Beck Depression Inventory for Primary Care
- Diagnosis
- See Major Depression Diagnosis
- See Major Depression for symptoms
- Differential Diagnosis
- See Major Depression Differential Diagnosis
- Pediatric Bipolar Disorder
- Presents with irritability, sadness and Insomnia (euphoria is typically absent)
- Persistent Depressive Disorder (Dysthymia)
- Depressed mood for more days than no depressed mood for at least one year
- Disruptive mood dysregulation
- Persistently angry with temper outbursts
- Post-Traumatic Stress Disorder may present in similar fashion
- Other associated conditions
- Eating Disorder
- Conduct Disorder
- Anxiety Disorder (comorbid with Major Depression in up to 74% of cases)
- Behavioral disorders (comorbid with Major Depression in up to 47% of cases)
- Management: Psychotherapy
- Cognitive behavior therapy (Behavioral activation techniques)
- Coping skill improvement
- Communication skill improvement
- Peer relationship improvement
- Problem solving techniques
- Negative thinking pattern resolution
- Emotional regulation
- Interpersonal therapy (limited to adolescents and older)
- Adaptation to relationship changes
- Personal role transitions
- Interpersonal relationship building
- Therapy Plan with Goal Examples
- Treat others with respect
- Eat family meals
- Maintain school work
- Spend time with peers in activities
- Safety Plan
- Limit access to lethal Suicide methods (e.g. firearms)
- References
- David-Ferdon (2008) J Clin Child Adolesc Psychol 37(1): 62-104 [PubMed]
- Weersing (2006) Child Adolesc Psychiatr Clin N Am 15(4): 939-57 [PubMed]
- Management: Medications
- Indications
- Moderate to severe depression
- Current depression with a prior episode
- Especially if treated with Antidepressants with the last episode
- Family History of depression
- Especially if significant response to medications in that family member
- Mood refractory to non-medication measures
- Refractory to modifications in environmental stressors
- Refractory to psychotherapy
- References
- Ryan (2003) Int J Methods Psychiatr Res 12(1): 44-53 [PubMed]
- Protocol
- Initial clinic visit
- Medication started
- Education of parents and patient
- Risks and benefits (see below)
- Common adverse effects of SSRIs and the delay in benefit for at leats 3-4 weeks
- Do not abrupty stop the SSRI (risk of Antidepressant Withdrawal)
- Warning signs to immediately seek medical attention
- Worsening depression
- Unusual behavior
- Suicidality
- Frequent phone calls (or clinic visits) after starting medication
- Schedule
- Every week for 4 weeks, then
- Every 2 weeks for 4 weeks
- Assess interim history
- Assess mood
- Assess for Suicidality
- Assess for Agitation, Insomnia, impulsivity (associated with Suicidality)
- Assess medication adverse effects
- Gastrointestinal adverse effects
- Nervousness
- Headache
- Motor restlessness
- Follow-up clinic visits
- Schedule (in addition to phone follow-up above)
- One month after starting medication
- Three months after starting medication
- Assess interim history
- Assess mood, Suicidality and adverse effects as above
- Titrate medication dose to effect
- Medication course
- Treat for at least 6 months after depression remission
- Selective Serotonin Reuptake Inhibitors
- All Antidepressants have an FDA black box warning regarding Suicidality risk in children
- Number Needed to Treat with SSRI for benefit in 1 child: 10
- Number needed to harm with SSRI for Suicidality in 1 child: 112
- Preferred SSRIs that are FDA approved
- Fluoxetine (Prozac)
- SSRI most consistently found effective in Childhood Depression and FDA approved
- Start at 10 mg and titrate at follow-up visit in 2 weeks
- Escitalopram (Lexapro)
- FDA approved for age 12 years and older
- Other SSRIs that are well tolerated and have some evidence of benefit
- Citalopram (Celexa)
- Sertraline (Zoloft)
- Other Antidepressants that are not recommended
- Paroxetine is not recommended in children due to increased Suicidality, adverse effects (per FDA)
- Tricyclic Antidepressants appear ineffective
- Venlafaxine has less evidence to support use, and may have increased risk of Suicidality
- No evidence supporting MAO inhibitors
- References
- (2014) Presc Lett 21(1): 5
- Management: Psychiatry referral indications
- Symptoms refractory to first-line medications despite titration of dose
- Children with depression under age 11 years old
- Chronic depression
- Comorbid Substance Abuse
- Suicidality (especially if a Suicide plan)
- Parental engagement lacking
- Complications
- Suicide
- See Suicide Screening
- See Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
- Seriously considered in 20% of teens
- Attempted Suicide in 8% of teens
- Growth Delay or Developmental Delay
- Impaired learning
- Persistent depression into adulthood (2-4 fold risk)
- Resources
- Patient Information: APA Guide to Medications in Children and Adolescents
- http://parentsmedguide.org/
- Suicide Prevention Lifeline
- Phone: (800) 273-TALK
- Crisis Text Line
- Text "HOME" to 741741
- References
- (2018) Presc Lett 25(6): 32-33
- Cheung (2007) Pediatrics 120(5): e1313-26 [PubMed]
- Cheung (2008) Curr Opin Pediatr 20(5): 551-9 [PubMed]
- Clark (2012) Am Fam Physician 85(5): 442-8 [PubMed]
- Selph (2019) Am Fam Physician 100(10):609-17 [PubMed]