Depression, Pediatric

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Depressed or irritable mood: feeling down, sad, or blue most of the time or being "annoyed" or "bothered" by everything and everyone

Diminished interest or pleasure in previously enjoyable activities (events, hobbies, interests)

Change in appetite or weight

Sleep disturbance: not feeling well rested, difficulty in waking up in the morning or in falling asleep at night, waking up in the middle of the night or too early in the morning, daytime napping or sleeping, and nighttime arousal

Psychomotor retardation or agitation: talk or move more slowly than typical, exhibit less speech, and longer response latencies; difficulty sitting still, pacing, hand wringing, tantrums, yelling, shouting, and nonstop talking

Fatigue or loss of energy: feeling chronically tired, exhausted, listless, and without energy or motivation (parents may interpret as laziness)

Feelings of worthlessness or guilt leading to reluctance to do things, excessive self-criticism, difficulty identifying positive self-attributes, "I don't care" attitude, envy or preoccupation with success of others, marked self-reproach or guilt for events that are not their fault

Impaired concentration or indecisiveness: problems with attention and concentration, slowed thinking and processing of information, indecisiveness and procrastination, helplessness or paralysis in taking action

Running or recurrent thoughts of death or suicide or attempts suicide

Diagnosis should also include assessment of distress and impairment of functioning.

Patient should not have manic or hypomanic behavior, and symptoms should not be attributable to substance use or another medical condition.

If symptoms do not fulfill criteria of MDD, consider dysthymic disorder or depressive disorder not otherwise specified (DSM IV-TR).

Dysthymic disorder: symptoms less intense but more persistent; depressed or irritable for at least 1 year with two of the following: appetite disturbance, sleep disturbance, fatigue, low self-esteem, poor concentration, difficulty making decisions, or feelings of hopelessness

Depressive disorder not otherwise specified: clinically significant depressive symptoms that do not meet criteria for MDD or dysthymic disorder

In DSM-5, dysthymic disorder and chronic MDD are combined in a new category, persistent depressive disorder.

Adjustment disorder with depressed mood is diagnosed when depressive symptoms occur only in the context of a specific stressor. Important to assess for the following symptoms:

Manic symptoms
- Ask about episodes of elevated or irritated mood associated with increased energy and activity, decreased need for sleep, grandiose thinking, and impulsive behavior.
- History of manic symptoms suggests bipolar disorder.
Premenstrual timing of symptoms
- If depressed mood is primarily in the days prior to menses, diagnosis may be premenstrual dysphoric disorder.
Psychotic symptoms
- Ask about auditory or visual hallucination, paranoid ideation, and odd beliefs, which suggest either a more serious depression, or a separate psychotic diagnosis.
- If family reports patient as withdrawn and less motivated, with no clear evidence for sad or irritable mood, this may also suggest a psychotic disorder.

Physical Exam
Weight loss or gain may be associated with depression. Somatic complaints (i.e., headaches, abdominal pain) are common in depression. Physical exam should focus on identifying medical conditions that cause depressive symptoms (hypothyroidism, neurologic conditions, and underlying chronic illness) and evaluating for signs of comorbid conditions such as eating disorders.

Vital signs: weight loss or weight gain
Goiter (hypothyrodism)
Lymphadenopathy (chronic illness, infection)
Sexual development (delayed puberty may be related to hypothyroidism, anorexia nervosa)
Extremities: arthritis (rheumatologic disease)
Neurologic exam (postconcussive symptoms)
Skin: pale, cool, dry (hypothyroidism); evidence of self-injurious behavior (i.e., scars from repetitive wrist cutting)
Mental status exam
- Appearance, alertness, speech, behavior
- Awareness of environment (orientation)
- Assessment of mood and affect
- Memory, judgment, reasoning
- Motoric slowing indicates severe depression.
- Abnormal thought content, such as current suicidal ideation or psychotic thoughts, should prompt immediate referral.

Diagnostic Tests & Interpretation
Lab

Vitamin B12, free T4, TSH, or other labs based on history and exam to identify contributing or associated medical condition
Screening for substance abuse as indicated

Differential Diagnosis

Medical
- Mood disorder related to a medical condition
- Endocrine: hypothyroidism, Addison disease
- Neurologic: postconcussive syndrome
- Metabolic: vitamin B12 deficiency
- Autoimmune: systemic lupus erythematosus
- Infectious: mononucleosis, HIV/AIDS
Behavioral
- Substance-induced mood disorder
Psychiatric
- Adjustment disorder with depressed mood
- Bipolar disorder

Treatment

Assessment of severity of depression
- Determine severity by considering number of symptoms, thought content and process, risk for suicidal behavior, and impact on functioning.
- Mild depression: 5 or 6 symptoms with mild impairment in functioning
- Moderate depression: 6-8 symptoms with mild to moderate impairment in functioning
- Severe depression: all 9 symptoms or 5 or more symptoms and reports specific suicide plan, clear intent, or recent attempt; psychotic symptoms; severe impairment in functioning (i.e., inability to leave home)
Safety assessment and planning
- Instruct family to remove lethal means and monitor risk factors for suicidal behavior.
- Provide patient and family with emergency contacts if risks for suicidal behavior increase.
- Establish clear follow-up plan.
Initial management of mild depression
- Supportive management including education of patient and family about depression and stress reduction, clinical and community support, and management of identified stressors
- Schedule visits with primary care clinician weekly or biweekly for 6-8 weeks for monitoring.
- If depression worsens or does not improve in 4-6 weeks, additional intervention is needed.
Management of moderate or persistent (lasting more than 6-8 weeks) depression
- Education, support, stress reduction
- Psychosocial interventions (counseling, therapy), antidepressant medication, or combination of both
- Among adolescents, psychosocial and medical interventions are equally effective, with slightly increased benefit with combination. Choice of intervention depends on resources, patient/family preference, and individual clinical factors (i.e., age, severity of depression, family history of treatment response).
- Among adolescents, 1st-line antidepressant medication is selective serotonin reuptake inhibitors (SSRIs).
- Among preadolescent children, little evidence for effectiveness of antidepressant medication with elevated risk of serious side effects; refer to child psychiatrist if antidepressants needed
- Antidepressant use in adolescents and young adults are associated with a slight increase in risk of suicidal thoughts and behaviors. These medications, however, have a favorable risk benefit ratio and can be used safely with appropriate patient education and monitoring.
- Omega-3 fatty acids (1,000 mg/day) may be effective in both children and adolescents.
- If patient is referred for therapy, continue frequent monitoring until depression is resolved.
- Several types of therapy can be used for depression. For adolescents, evidence for effectiveness of cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT)
Special diagnostic considerations
- Premenstrual dysphoric disorder: SSRIs can be used as the 1st-line treatment.
- Adjustment disorder: When depressed mood is only in context of a specific stressor, psychosocial interventions, rather than medications, are recommended.

Issues for Referral

Patients with depression can be successfully managed by primary care clinicians. Referral to a mental health provider is recommended for the following:

Risk for acute suicidal behavior: Refer to emergency services (child crisis).
History of suicide attempts
Presence of substance abuse
Presence of manic or psychotic symptoms
No improvement after 6-8 weeks of treatment
Recurrent or chronic depression
Severe functional impairment
Psychiatric comorbidities
Complicated psychosocial factors, such as dysfunctional family dynamics
After initiating referral to a mental health provider, primary care clinician should continue to follow patient while he or she waits for an appointment and throughout treatment course.

Ongoing Care

Follow-up Recommendations

In the initial phase (6-9 months or longer), the primary care clinician must identify medical conditions associated with depression, provide support and resources, assess patient safety and review safety plan, and monitor response to psychosocial and medical treatments.
In the continuation phase (6-12 months), patients continue psychosocial or pharmacologic treatments used to achieve remission in the acute phase for at least 6 months, 12 months if difficulties in achieving remission, history of recurrent depression, or presence of ongoing risk factors; patients are typically seen biweekly or monthly by mental health providers depending on clinical status, functioning, support systems, stressors, motivation for treatment, and comorbid psychiatric or medical disorders.
When asymptomatic for 6-12 months, patients may be recommended for either maintenance phase or discontinuation of treatment.

Prognosis

Up to 30-40% of patients with MDD can be expected to recover by 6 months and 70-80% by 12 months; 5-10% have protracted episodes lasting longer than 2 years.
Time to recovery is influenced by age at onset of illness, severity, presence of comorbid disorders, and parental history of depression.
Shorter duration of symptoms at the time of diagnosis is associated with better outcomes; thus, early identification is recommended.
Probability of recurrence following recovery of a major depressive episode is approximately 40% by 2 years and 70% by 5 years.

Additional Reading

Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120(5):e1313-e1326. [View Abstract]
Greydanus DE, Calles JL, Patel DR. Pediatric and Adolescent Psychopharmacology: A Practical Manual for Pediatricians. Cambridge, United Kingdom: University Press; 2008.
Lewandowski RE, Acri MC, Hoagwood KE, et al. Evidence for the management of adolescent depression. Pediatrics. 2013;132(4):e996-e1009. [View Abstract]
March J, Silva S, Petrycki S, et al; Treatment for Adolescents with Depression Study (TADS) Team. Fluoxetine, cognitive behavioral therapy, and their combination for adolescents with depression: treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820. [View Abstract]
Rao U, Chen LA. Characteristics, correlates, and outcomes of childhood and adolescent depressive disorders. Dialogues Clin Neurosci. 2009;11(1):45-62. [View Abstract]
Williams SB, O'Connor EA, Eder M, et al. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009;123(4):e716-e735. [View Abstract]
Zuckerbrot RA, Cheung AH, Jensen PS, GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120(5):e1299-e1312. [View Abstract]

Codes

ICD09

311 Depressive disorder, not elsewhere classified
296.20 Major depressive affective disorder, single episode, unspecified
300.4 Dysthymic disorder
296.30 Major depressive disorder, recurrent episode, unspecified degree
300.9 Unspecified nonpsychotic mental disorder

ICD10

F32.9 Major depressive disorder, single episode, unspecified
F33.9 Major depressive disorder, recurrent, unspecified
F34.1 Dysthymic disorder
F32.8 Other depressive episodes
F33.8 Other recurrent depressive disorders
F32.3 Major depressv disord, single epsd, severe w psych features
F32.2 Major depressv disord, single epsd, sev w/o psych features

SNOMED

35489007 Depressive disorder (disorder)
36923009 Major depression, single episode (disorder)
78667006 Dysthymia (disorder)
66344007 Recurrent major depression (disorder)

FAQ

Q: What is the PHQ-9?
A: The PHQ-9 is a self-completed screening survey composed of 9 questions that ask about the frequency of symptoms of depression. If a patient reports 5 or more symptoms more than half the days during the past 2 weeks, the clinician must consider MDD as a diagnosis.
Q: How should clinicians interpret the "Black Box Warning" about SSRIs?
In 2004, the Food and Drug Administration issued the Black Box Warning, the most serious type of warning in prescription drug labeling, to inform the public about increased risk of suicidal thoughts or behavior in children and adolescents treated with SSRI. Given evidence for improvement of depression with SSRIs, clinicians should weigh the risks and benefits with the patient and family in deciding treatment; adolescents treated with SSRIs must be closely monitored for any worsening in depression, emergence of suicidal thinking or behavior, or unusual changes in behavior, such as sleeplessness, agitation, or withdrawal from normal social situations.
Q: What is CBT?
A: In CBT, the therapist guides and helps a patient to understand and modify dysfunctional thoughts, feelings, and behaviors. If a patient believes that he is worthless, the therapist may encourage him to challenge the negative and irrational belief by understanding patterns in his thinking that relate to such a belief.

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