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Depressive Disorders in Children and Adolescents

by Josephine Elia, MD

(See also Depressive Disorders.)

Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by history and examination. Treatment is with antidepressants, supportive and cognitive-behavioral therapy, or both.

Depressive disorders in children and adolescents include

  • Disruptive mood dysregulation disorder

  • Major depressive disorder

  • Persistent depressive disorder (dysthymia)

The term depression is often loosely used to describe the low or discouraged mood that results from disappointment (eg, serious illness) or loss (eg, death of a loved one). However, such low moods, unlike depression, occur in waves that tend to be tied to thoughts or reminders of the triggering event, resolve when circumstances or events improve, may be interspersed with periods of positive emotion and humor, and are not accompanied by pervasive feelings of worthlessness and self-loathing. The low mood usually lasts days rather than weeks or months, and suicidal thoughts and prolonged loss of function are much less likely. Such low moods are more appropriately called demoralization or grief. However, events and stressors that cause demoralization and grief can also precipitate a major depressive episode.

The etiology of depression in children and adolescents is unknown but is similar to that in adults (see Depressive Disorders : Etiology); it is believed to result from interactions of genetically determined risk factors and environmental stress (particularly deprivation and loss early in life).

Symptoms and Signs

Basic manifestations are similar to those in adults but are related to typical concerns of children, such as schoolwork and play. Children may be unable to explain inner feelings or moods. Depression should be considered when previously well-performing children do poorly in school, withdraw from society, or commit delinquent acts.

In some children with a depressive disorder, the predominant mood is irritability rather than sadness (an important difference between childhood and adult forms). The irritability associated with childhood depression may manifest as overactivity and aggressive, antisocial behavior.

In children with intellectual disability, depressive or other mood disorders may manifest as somatic symptoms and behavioral disturbances.

Disruptive mood dysregulation disorder

Disruptive mood dysregulation disorder involves persistent irritability and frequent episodes of behavior that is very out of control, with onset at age 6 to 10 yr. Many children also have other disorders, particularly oppositional defiant disorder (see Oppositional Defiant Disorder), attention-deficit/hyperactivity disorder (ADHD), or an anxiety disorder. The diagnosis is not applied after age 18. As adults, patients may develop unipolar (rather than bipolar) depression or an anxiety disorder.

Manifestations include the presence of the following for ≥ 12 mo (with no period of ≥ 3 mo without all of them):

  • Severe recurrent temper outbursts (eg, verbal rage and/or physical aggression toward people or property) that are grossly out of proportion to the situation and that occur ≥ 3 times/wk on average

  • Temper outbursts that are inconsistent with developmental level

  • An irritable, angry mood present every day for most of the day and observed by others (eg, parents, teachers, peers)

The outbursts and angry mood must occur in 2 of 3 settings (at home or school, with peers).


Major depressive disorder

Major depressive disorder is a discrete depressive episode lasting ≥ 2 wk. It occurs in as many as 2% of children and 5% of adolescents. Major depressive disorder can first occur at any age but is more common after puberty. Untreated, major depression may remit in 6 to 12 mo. Risk of recurrence is higher in patients who have severe episodes, who are younger, or who have had multiple episodes. Persistence of even mild depressive symptoms during remission is a strong predictor of recurrence.

For diagnosis, ≥ 1 of the following must be present for most of the day nearly every day during the same 2-wk period:

  • Feeling sad or being observed by others to be sad (eg, tearful) or irritable

  • Loss of interest or pleasure in almost all activities (often expressed as profound boredom)

In addition, ≥ 4 of the following must be present:

  • Decrease in weight (in children, failure to make the expected weight gain) or decrease or increase in appetite

  • Insomnia or hypersomnia

  • Psychomotor agitation or retardation observed by others (not self-reported)

  • Fatigue or loss of energy

  • Decreased ability to think, concentrate, and make choices

  • Recurrent thoughts of death (not just fear of dying) and/or suicidal ideation or plans

  • Feelings of worthlessness (ie, feeling rejected and unloved) or excessive or inappropriate guilt

Major depression in adolescents is a risk factor for academic failure, substance abuse, and suicidal behavior (see Suicidal Behavior in Children and Adolescents). While depressed, children and adolescents tend to fall far behind academically and lose important peer relationships.


Persistent depressive disorder (dysthymia)

Dysthymia is a persistent depressed or irritable mood that lasts for most of the day for more days than not for ≥ 1 yr plus ≥ 2 of the following:

  • Poor appetite or overeating

  • Insomnia or hypersomnia

  • Low energy or fatigue

  • Low self-esteem

  • Poor concentration

  • Feelings of hopelessness

A major depressive episode may occur before the onset or during the first year (ie, before the duration criterion is met for persistent depressive disorder).


Diagnosis

  • Clinical evaluation

Diagnosis is based on symptoms and signs, including the criteria listed above. A careful review of the history and appropriate laboratory tests are needed to exclude other disorders (eg, infectious mononucleosis, thyroid disorders, drug abuse). History should include causative factors such as domestic violence, sexual abuse and exploitation, and drug adverse effects. Questions about suicidal behavior (eg, ideation, gestures, attempts) should be asked.

Other mental disorders that can increase the risk and/or modify the course of depressive symptoms (eg, anxiety, bipolar disorders) must be considered. Some children who eventually develop a bipolar disorder or schizophrenia may present initially with major depression.

After depression is diagnosed, the family and social setting must be evaluated to identify stresses that may have precipitated depression.

Treatment

  • Concurrent measures directed at the family and school

  • For adolescents, usually antidepressants plus psychotherapy

  • For preadolescents, psychotherapy followed, if needed, by antidepressants

Appropriate measures directed at the family and school must accompany direct treatment of the child to enhance continued functioning and provide appropriate educational accommodations. Brief hospitalization may be necessary in acute crises, especially when suicidal behavior is identified.

For adolescents (as for adults), a combination of psychotherapy and antidepressants usually greatly outperforms either modality used alone. For preadolescents, the situation is much less clear. Most clinicians opt for psychotherapy in younger children; however, drugs can be used in younger children (fluoxetine can be used in children 8 yr), especially when depression is severe or has not previously responded to psychotherapy.

Usually, an SSRI (see Table: Drugs for Long-Term Treatment of Anxiety and Related Disorders) is the first choice when an antidepressant is indicated. Children should be closely monitored for the emergence of behavioral side effects (eg, disinhibition, behavioral activation—see footnote in Drugs for Long-Term Treatment of Anxiety and Related Disorders). Adult-based research has suggested that antidepressants that act on both the serotonergic and adrenergic/dopaminergic systems may be modestly more effective; however, such drugs (eg, duloxetine, venlafaxine, mirtazapine; certain tricyclics, particularly clomipramine) also tend to have more adverse effects. Such drugs may be especially useful in treatment-resistant cases. Nonserotonergic antidepressants such as bupropion and desipramine may also be used with an SSRI to enhance efficacy.

As in adults, relapse and recurrence are common. Children and adolescents should remain in treatment for at least 1 yr after symptoms have remitted. Most experts recommend that children who have experienced 2 episodes of major depression be treated indefinitely.

Suicide risk and antidepressants

Suicide risk and treatment with antidepressants have been a topic of debate and research 1 . In 2004, the US FDA did a meta-analysis of 23 previously conducted trials of 9 different antidepressants 2 . Although no patients completed suicide in these trials, a small but statistically significant increase in suicidal ideation was noted in children and adolescents taking an antidepressant (about 4% vs about 2%), leading to a black box warning on all classes of antidepressants (eg, tricyclic antidepressants, SSRIs, serotonin-norepinephrine reuptake inhibitors such as venlafaxine, tetracyclic antidepressants such as mirtazapine).

In 2006, a meta-analysis 3 (from the United Kingdom) of children and adolescents being treated for depression found that compared with patients taking a placebo, those taking an antidepressant had a small increase in self-harm or suicide-related events (4.8% vs 3.0% of those treated with placebo). However, whether the difference was statistically significant or not varied depending on the type of analysis (fixed-effects analysis or random-effects analysis). There was a nonsignificant trend toward an increase in suicidal ideation (1.2% vs 0.8%), self-harm (3.3% vs 2.6%), and suicide attempts (1.9% vs 1.2%). There appear to have been some differences in risk between different drugs; however, no direct head-to-head studies have been done, and it is difficult to control for severity of depression and other confounding risk factors.

Observational and epidemiologic studies 4 have found no increase in the rate of suicide attempts or completed suicide in patients takings antidepressants. Also, despite a decrease in prescriptions for antidepressants, the suicide rate has increased.

In general, although antidepressants have limited efficacy in children and adolescents, the benefits appear to outweigh risks. The best approach seems to be combining drug treatment with psychotherapy and minimizing risk by closely monitoring treatment.

Whether or not drugs are used, suicide is always a concern in a child or adolescent with depression. The following should be done to reduce risk:

  • Parents and mental health care practitioners should discuss the issues in depth.

  • The child or adolescent should be supervised at an appropriate level.

  • Psychotherapy with regularly scheduled appointments should be included in the treatment plan.

  • 1 Hetrick SE, McKenzie JE, Merry SN : Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database Syst Rev Nov 11 2012.

  • 2 US FDA : Review and evaluation of clinical data: Relationship between psychotropic drugs and pediatric suicidality. 2004. Accessed 3/24/14.

  • 3 Dubicka B, Hadley S, Roberts C : Suicidal behaviour in youths with depression treated with new-generation antidepressants: Meta-analysis. Br J Psychiatry Nov 189:393–398, 2006.

  • 4 Adegbite-Adeniyi C, et al : An update on antidepressant use and suicidality in pediatric depression. Expert Opin Pharmacother 13(15):2119–2130, 2012.


Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ANAFRANIL
  • CYMBALTA
  • PROZAC, SARAFEM
  • EFFEXOR XR
  • WELLBUTRIN, ZYBAN
  • NORPRAMIN
  • REMERON
  • LEVOPHED

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