Childhood Depression

1. See Also
   1. Major Depression
2. Epidemiology
   1. Incidence: 5% in ages 9-17 years old
      1. Depressed mood occurs in up to 20% of teens
   2. Gender predominance: Girls by 2 fold
3. Precautions
   1. Missed or incorrect diagnosis occurs in up to 70%
   2. Pitfalls in diagnosis
      1. Atypical presentations: Headaches, Stomache pain
      2. Downplayed symptoms if parents are also depressed
4. Risk factors
   1. Comorbid illness
   2. Puberty-related hormonal changes
   3. Family History of depression
   4. Medications: Accutane
   5. Emotional stressors (e.g. relationship break-ups)
   6. Child Abuse
   7. Tobacco abuse
   8. Attention Deficit Disorder
5. Screening
   1. See Depression Screening Tools
   2. Ages 7 to 17 years old
      1. Childrens Depression Inventory (CDI)
   3. Ages 8 to 12 years old
      1. Reynolds Child Depression Scale
   4. Ages 13 to 18 years old
      1. Reynolds Adolescent Depression Scale
   5. Ages 13 and older
      1. Obtain Patient Health Questionnaire-2 (PHQ-2) each year at routine visit
      2. Patient Health Questionnaire-9 (PHQ-9)
   6. Ages 14 and older
      1. Beck Depression Inventory for Primary Care
6. Diagnosis
   1. See Major Depression Diagnosis
7. Differential Diagnosis
   1. See Major Depression Differential Diagnosis
   2. Pediatric Bipolar Disorder
      1. Presents with irritability, sadness and Insomnia (euphoria is typically absent)
8. Management: Psychotherapy
   1. Cognitive behavior therapy (Behavioral activation techniques)
      1. Coping skill improvement
      2. Communication skill improvement
      3. Peer relationship improvement
      4. Problem solving techniques
      5. Negative thinking pattern resolution
      6. Emotional regulation
   2. Interpersonal therapy (limited to adolescents and older)
      1. Adaptation to relationship changes
      2. Personal role transitions
      3. Interpersonal relationship building
   3. References
      1. David-Ferdon (2008) J Clin Child Adolesc Psychol 37(1): 62-104 [PubMed]
      2. Weersing (2006) Child Adolesc Psychiatr Clin N Am 15(4): 939-57 [PubMed]
9. Management: Medications
   1. Indications
      1. Moderate to severe depression
      2. Current depression with a prior episode
         1. Especially if treated with Antidepressants with the last episode
      3. Family History of depression
         1. Especially if significant response to medications in that family member
      4. Mood refractory to non-medication measures
         1. Refractory to modifications in environmental stressors
         2. Refractory to psychotherapy
      5. References
         1. Ryan (2003) Int J Methods Psychiatr Res 12(1): 44-53 [PubMed]
   2. Protocol
      1. Initial clinic visit
         1. Medication started
         2. Education of parents and patient
            1. Risks and benefits (see below)
            2. Common adverse effects of SSRIs and the delay in benefit for at leats 3-4 weeks
            3. Do not abrupty stop the SSRI (risk of Antidepressant Withdrawal)
            4. Warning signs to immediately seek medical attention
               1. Worsening depression
               2. Unusual behavior
               3. Suicidality
      2. Frequent phone calls (or clinic visits) after starting medication
         1. Schedule
            1. Every week for 4 weeks, then
            2. Every 2 weeks for 4 weeks
         2. Assess interim history
            1. Assess mood
            2. Assess for Suicidality
            3. Assess for Agitation, Insomnia, impulsivity (associated with Suicidality)
         3. Assess medication adverse effects
            1. Gastrointestinal adverse effects
            2. Nervousness
            3. Headache
            4. Motor restlessness
      3. Follow-up clinic visits
         1. Schedule (in addition to phone follow-up above)
            1. One month after starting medication
            2. Three months after starting medication
         2. Assess interim history
            1. Assess mood, Suicidality and adverse effects as above
            2. Titrate medication dose to effect
      4. Medication course
         1. Treat for at least 6 months after depression remission
   3. Selective Serotonin Reuptake Inhibitors
      1. All Antidepressants have an FDA black box warning regarding Suicidality risk in children
         1. Number Needed to Treat with SSRI for benefit in 1 child: 10
         2. Number needed to harm with SSRI for Suicidality in 1 child: 112
      2. Preferred SSRIs
         1. Fluoxetine (Prozac)
            1. SSRI most consistently found effective in Childhood Depression
            2. Start at 10 mg and titrate at follow-up visit in 2 weeks
         2. Citalopram (Celexa)
         3. Sertraline (Zoloft)
         4. Escitalopram (Lexapro)
            1. FDA approved for age 12 years and older
   4. Other Antidepressants that are not recommended
      1. Paroxetine is not recommended in children due to increased Suicidality, adverse effects (per FDA)
      2. Tricyclic Antidepressants appear ineffective
      3. Venlafaxine has less evidence to support use, and may have increased risk of Suicidality
      4. No evidence supporting MAO inhibitors
   5. References
      1. (2014) Presc Lett 21(1): 5
10. Management: Psychiatry referral indications
    1. Symptoms refractory to first-line medications despite titration of dose
    2. Children with depression under age 11 years old
    3. Chronic depression
    4. Comorbid Substance Abuse
    5. Suicidality (especially if a Suicide plan)
    6. Parental engagement lacking
11. Complications
    1. Suicide
       1. Seriously considered in 20% of teens
       2. Attempted Suicide in 8% of teens
    2. Growth delay or Developmental Delay
    3. Impaired learning
    4. Persistent depression into adulthood (2-4 fold risk)
12. Resources
    1. Patient Information: APA Guide to Medications in Children and Adolescents
       1. http://parentsmedguide.org/
    2. Suicide Prevention Lifeline
       1. Phone: (800) 273-TALK
    3. Crisis Text Line
       1. Text "HOME" to 741741
13. References
    1. (2018) Presc Lett 25(6): 32-33
    2. Cheung (2007) Pediatrics 120(5): e1313-26 [PubMed]
    3. Cheung (2008) Curr Opin Pediatr 20(5): 551-9 [PubMed]
    4. Clark (2012) Am Fam Physician 85(5): 442-8 [PubMed]