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Parents are more likely to indicate externalized symptoms such as irritability, whereas children are more likely to report internalized symptoms such as depressed mood. 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. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Symptoms are not caused by the direct physiologic effects of a substance e. Symptoms are not caused by bereavement i. Reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. When considering a diagnosis of depression, physicians must also consider likely medical causes of the presenting symptoms, such as hyper- or hypothyroidism, anemia, or use of certain medications, including isotretinoin Table 4. Childhood and adolescent depression: the role of primary care providers in diagnosis and treatment. Other psychological illnesses have presentations in children and adolescents that are similar to depression, especially adjustment, dysthymic, and bipolar disorders.
Adjustment disorder with depressed mood can be mistaken for major depressive disorder; symptoms of both conditions include depressed mood, tearfulness, and feelings of hopelessness. However, the symptoms of adjustment disorder are related to a specific event and do not meet all criteria of a major depressive episode. Dysthymic disorder in children and adolescents is characterized by depressed mood on most days for one year.
Patients with dysthymia meet a subset of criteria for major depression, but the course of the illness is longer and the symptoms are less severe. Depressive symptoms may manifest as irritability in children and adolescents, and patients often have low self-esteem and poor social skills. It is important to rule out bipolar disorder when diagnosing depression, because antidepressant medications can initiate manic symptoms. The presence of a psychiatric disorder is one of the strongest correlates for suicide across age groups.
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Asking about suicide or using depression screening tools can be a means for assessing suicidal ideation in children and adolescents in the primary care setting. However, further inquiry into patient symptoms may be required because some tools lack specificity or are prone to oversensitivity. If a patient has suicidal thoughts, further assessment should include questions about the frequency of thoughts; the presence and specificity of a plan; the lethality or availability of means to follow through with the plan; whether there are protective factors, such as social support; and whether there are any other factors, such as substance use or a previous suicide attempt.
If it is determined that a patient is at risk of self-harm, urgent referral to a mental health professional or emergency department is warranted. Interventions for patients at lower risk of self-harm include involving parents or caregivers to provide close observation of the patient, and removing any weapons or means to self-harm. The frequency of follow-up visits may be increased, and patients may benefit from education on how to seek assistance after hours e.
Treatment of childhood and adolescent depression consists of psychotherapy, pharmacotherapy, or a combination of these. Treatment should correspond to the level of depression, patient preferences, the developmental level of the patient, associated risk factors, and availability of services.
The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry recommend that psychotherapy always be a component of treatment for childhood and adolescent depression. Cognitive behavior therapy CBT and interpersonal therapy have been proven effective in the treatment of adolescent depression, and CBT has been proven effective in the treatment of childhood depression. CBT usually consists of behavioral activation techniques and methods to increase coping skills, improve communication skills and peer relationships, solve problems, combat negative thinking patterns, and regulate emotions.
Although psychotherapy is a major component in the treatment of childhood and adolescent depression, adjuvant use of medication is sometimes appropriate.
Treatment of Childhood and Adolescent Depression
Considerations for initiating antidepressant therapy include depression severity and history Table 5. Is there a family history of depression with significant response to medication? Have environmental stressors been modified with no associated improvements in mood? Has evidence-based psychotherapy i. Information from references 43 and Tricyclic antidepressants were previously used to treat depression in children, but studies have shown little to no benefit in adolescents and children. Treatment should begin at the lowest dosage available and titrated according to the patient's response and adverse effects.
If initial first-line therapy is ineffective, another first-line agent should be considered. All antidepressants have a boxed warning for an increased risk of suicide; therefore, close monitoring is recommended e. Treatment of depression in children and adolescents should continue for six months after remission.
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The decision to continue treatment for four to six months after remission of symptoms should be based on prior recurrent episodes of depression and current psychological and social stressors. Children younger than 11 years and those with chronic depression, comorbid substance use, psychiatric disorders, suicidality with plan, or lack of parental engagement in treatment should be referred to a psychiatrist. Preventive Services Task Force, PubMed, Ovid Medline, and PsycINFO using the keywords childhood and adolescent depression, major depression and adolescents, major depression and childhood, major depression and children, depression and children, and depression and adolescents.
The search included reviews, meta-analyses, randomized controlled trials, and clinical trials. Search dates: March 5 and 11, Already a member or subscriber? Log in. KATE L. Address correspondence to Molly S. Reprints are not available from the authors. Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatry. Depressed adolescents grown up. Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. Mental health, educational, and social role outcomes of adolescents with depression. Arch Gen Psychiatry. Health outcomes related to early adolescent depression.
J Adolesc Health. Affective disorders in children and adolescents: addressing unmet need in primary care settings. Biol Psychiatry. Mood disorders in children and adolescents: an epidemiologic perspective. Richardson LP, Katzenellenbogen R. Pediatric depressive disorders: management priorities in primary care. Curr Opin Pediatr. History of the use of antidepressants in primary care. Pediatric depression: is there evidence to improve evidence-based treatments? Prevention of childhood depression: recent findings and future prospects.
Childhood and adolescent depression: a review of the past 10 years. Part I. Part II. Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: recommendation statement [published correction appears in Pediatrics. Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care.
Behav Res Ther. An inventory for measuring depression. Kovacs M. Children's Depression Inventory Manual. Screening for major depression disorders in adolescent medical outpatients with the Beck Depression Inventory for Primary Care. Assessing depression in youth: relation between the Children's Depression Inventory and a structured interview. J Clin Child Adolesc Psychol. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents.
Screening for depression: systematic evidence review. Accessed August 3, Reliability and validity of the Reynolds Adolescent Depression Scale with young adolescents. J Sch Psychol. American Psychiatric Association. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Toward guidelines for evidence-based assessment of depression in children and adolescents.
Epidemiology of completed and attempted suicide: toward a framework for prevention. Clin Neurosci Res. National Institute of Mental Health.
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Suicide in the U. Accessed March 11, Suicide screening in schools, primary care and emergency departments. Suicide and suicide attempts in adolescents. Identification, assessment, and initial management. The use of medication in treating childhood and adolescent depression: information for patients and families. Accessed March 5, Neural responses to sad facial expressions in major depression following cognitive behavioral therapy. Cognitive behavioral therapy for depression in youth. Evidence-based psychosocial treatments for child and adolescent depression. Effects of psychotherapy for depression in children and adolescents: a meta-analysis.
Psychol Bull. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study TADS randomized controlled trial. Klomek AB, Mufson L. Interpersonal psychotherapy for depressed adolescents. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. J Consult Clin Psychol. Ryan ND. Child and adolescent depression: short-term treatment effectiveness and long-term opportunities. Int J Methods Psychiatr Res. Continuation and maintenance therapy of early-onset major depressive disorder.
Paediatr Drugs. Childhood and adolescent depression: why do children and adults respond differently to antidepressant drugs? Neurochem Int. Tricyclic drugs for depression in children and adolescents Cochrane Database Syst Rev. Cincinnati Children's Hospital Medical Center. Best evidence statement: treatment of children and adolescents with major depressive disorder MDD during the acute phase. Accessed November 28, Treatment and ongoing management.