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 clinical criteria. Treatment is with antidepressants, supportive and cognitive-behavioral therapy, or a combination of these modalities.
(See also discussion of Depressive Disorders in adults.)
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 etiology in adults; it is believed to result from interactions of genetically determined risk factors and environmental stress (particularly early life stress such as abuse, injury, natural disaster, domestic violence, death of family member, and deprivation [1]).
During the COVID-19 pandemic, depression symptoms doubled in youths, especially in older adolescents (2) and mental health care visits for depression increased by 43% (3). After controlling for child gender, age and pre-COVID-19 depressive symptoms, connectedness to caregivers and child screen time were significant predictors of child COVID-19 depressive symptoms (4).
General references
1. LeMoult J, Humphreys KL, Tracy A, et al: Meta-analysis: Exposure to early life stress and risk for depression in childhood and adolescence. J Am Acad Child Adolesc Psychiatry 59(7);842-855, 2020. doi: https://doi.org/10.1016/j.jaac.2019.10.011
2. Racine N, McArthur B, Cooke J, et al: Global prevalence of depressive and anxiety symptoms in children and adolescence during COVID-19: A meta-analysis. JAMA Pediatr 175(11):1142-1150, 2021. doi: 10.1001/jamapediatrics.2021.2482
3. Dvir Y, Ryan C, Straus JH: Comparison of use of the Massachusetts Child Psychiatry Access Program and patient characteristics before vs during the COVID-19 pandemic. JAMA Netw Open5(2):e2146618, 2022. doi:10.1001/jamanetworkopen.2021.46618
4. McArthur BA, Racine N, McDonald S, et al: Child and family factors associated with child mental health and well-being during COVID-19. Eur Child Adolesc Psychiatry Jul 24;1-11, 2021. doi: 10.1007/s00787-021-01849-9
Symptoms and Signs
Basic manifestations of depressive disorders in children and adolescents 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 years. Many children also have other disorders, particularly oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), or an anxiety disorder. The diagnosis is not made before age 6 years or after age 18 years. As adults, patients may develop unipolar (rather than bipolar) depression or an anxiety disorder.
Manifestations include the presence of the following for ≥ 12 months (with no period of ≥ 3 months 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/week 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 weeks. 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 months. 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-week 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 use, and suicidal behavior. While depressed, children and adolescents tend to fall far behind academically and lose important peer relationships. In very severe depression, psychotic symptoms may emerge.
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 year plus ≥ 2 of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration
Feelings of hopelessness
Symptoms may be more or less intense than those of a major depressive disorder.
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
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5-TR) criteria
Diagnosis of depressive disorders is based on symptoms and signs, including the criteria listed above.
Sources of information include an interview with the child or adolescent and information from parents and teachers. Several brief questionnaires are available for screening. They help identify some depressive symptoms but cannot be used alone for diagnosis. Specific close-ended questions help determine whether patients have the symptoms required for diagnosis of major depression, based on DSM-5-TR criteria.
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.
A careful review of the history and appropriate laboratory tests are needed to exclude other disorders (eg, infectious mononucleosis, thyroid disorders, substance use disorders) that can cause similar symptoms.
Other psychiatric disorders that can increase the risk and/or modify the course of depressive symptoms (eg, anxiety and 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 (1≥ 8 years), especially when depression is severe or has not previously responded to psychotherapy.
Usually, a selective serotonin reuptake inhibitor (SSRI; see table Medications for Long-Term Treatment of Depression, Anxiety, and Related Disorders) is the first choice when an antidepressant is indicated (2). Children should be closely monitored for the emergence of behavioral side effects (eg, disinhibition, behavioral activation), which are common but are usually mild to moderate. Usually, decreasing the medication dose or changing to a different medication eliminates or reduces these effects. Rarely, such effects are severe (eg, aggressiveness, increased suicidality). Behavioral adverse effects are idiosyncratic and may occur with any antidepressant and at any time during treatment. As a result, children and adolescents taking such drugs must be closely monitored.
antipsychotic medication (3, 4).
Transcranial magnetic stimulation—although not yet approved by the Food and Drug Administration (FDA) for use in youths—has been used, particularly when patients do not respond to or tolerate medications (5). Preliminary studies of transcranial magnetic stimulation in adolescents show similar clinical effects and tolerability as in adults (5–8). Larger ongoing studies will soon provide more data on noninvasive brain stimulation in adolescent depression (7).
As in adults, relapse and recurrence are common. Children and adolescents should remain in treatment for at least 1 year after symptoms have remitted. Most experts recommend that children who have experienced ≥ 2 episodes of major depression be treated indefinitely.
Treatment references: General
1. Kennard BD, Silva SG, Tonev S, et al: Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): Acute and long-term outcomes. J Am Acad Child Adolesc Psychiatry 48(2):186-195, 1009. doi: 10.1097/CHI.0b013e31819176f9
2. Dwyer JB, Bloch MH: Antidepressants for pediatric patients. Curr Psychiatr 8(9):26-42F, 2019.
3. Kendall T, Morriss R, Mayo-Wilson E, et al: Assessment and management of bipolar disorder: Summary of updated NICE guidance. BMJ 349:g5673, 2014. doi: 10.1136/bmj.g5673
4. Yatham LN, Kennedy SH, Parikh SV, et al: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: Update 2013. Bipolar Disord 15(1):1-44, 2013. doi: 10.1111/bdi.12025
5. Allen CG, Kluger BM, Buard I: Safety of transcranial magnetic stimulation in children: A systematic review of the literature. Pediatr Neurol 68:3-17, 2017. doi.org/10.1016/j.pediatrneurol.2016.12.009
6. Donaldson AE, Gordon MS, Melvin GA, et al: Addressing the needs of adolescents with treatment resistant depressive disorders: A systematic review of rTMS. Brain Stimul 7(1):7-12. 2014. doi: 10.1016/j.brs.2013.09.012
7. Krishnan C, Santos L, Peterson MD, et al: Safety of noninvasive brain stimulation in children and adolescents. Brain Stimul 8:76-87, 2015. doi: 10.1016/j.brs.2014.10.012
8. Croarkin PE, MacMaster FP: Transcranial magnetic stimulation for adolescent depression. Child Adolesc Psychiatry Clin N Am 28(1):33-43, 2019. 10.1016/j.chc.2018.07.003
Suicide risk and antidepressants
Suicide risk and treatment with antidepressants have been topics 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
In 2006, a meta-analysis (from the United Kingdom) of children and adolescents being treated for depression (3) 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 medications; 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, 5) have found no increase in the rate of suicide attempts or completed suicide in patients taking antidepressants. Also, despite a decrease in prescriptions for antidepressants following the black-box warning, the adolescent suicide rate increased by 14% (6, 7). Using data from commercial claims (8) and nationwide registers (9) to estimate risks and benefits of medications in relation to suicidal events, SSRIs were associated with significantly decreased suicidal events.
In general, although antidepressants have limited efficacy in children and adolescents, the benefits appear to outweigh risks. The best approach seems to be combining treatment with medications with psychotherapy and minimizing risk by closely monitoring treatment.
Whether or not medications 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.
Pearls & Pitfalls
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Treatment references: Suicide risk and antidepressants
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 January 9, 2023.
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.
5. Gibbons RD, Brown CH, Hur K, et al: Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry 164 (9);1356–1363, 2007.
6. Garland JE, Kutcher S, Virani A, et al: Update on the use of SSRIs and SNRIs with children and adolescents in clinical practice. J Can Acad Child Adolesc Psychiatry 25(1):4-10.
7. Dwyer JB, Bloch MH: Antidepressants for pediatric patients. Curr Psychiatr 8(9):26-42F, 2019.
8. Gibbons R, Hur K, Lavigne J, et al: Medications and suicide: High dimensional empirical Bayes screening (iDEAS). Harvard Data Sci Rev 2019. doi: 10.1162/99608f92.6fdaa9de
9. Lagerberg T, Fazel S, Sjölander A, et al: Selective serotonin reuptake inhibitors and suicidal behaviour: A population-based cohort study. Neuropsychoparmacol 47:817-823, 2022. https://doi.org/10.1038/s41386-021-01179-z
Key Points
In children, depressive disorders may manifest as sadness or irritability.
Major depressive disorder involves feeling sad or irritable or losing interest or pleasure in almost all activities for most of the day nearly every day during a 2-week period plus other specific symptoms.
Diagnose a depressive disorder based on specific clinical criteria, and do appropriate laboratory tests to exclude other disorders (eg, infectious mononucleosis, thyroid disorders, illicit drug use).
Involve the family and school while treating the child to enhance the child's continued functioning and provide appropriate educational accommodations.
For adolescents (as for adults), a combination of psychotherapy and antidepressants usually greatly outperforms either modality used alone; in younger children, most clinicians opt for psychotherapy although if needed, medications can be used (depending on the child's age).
In 2004, the FDA did a meta-analysis that led to a black box warning of an increased risk of suicidal ideation and behavior in children, adolescents, and young adults with all classes of antidepressants; subsequent analyses have cast doubt on this conclusion.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
CPIC—Clinical Pharmacogenetics Implementation Consortium: This international consortium facilitates use of pharmacogenetic tests for patient care. The site provides access to guidelines to help clinicians understand how genetic test results should be used to enhance drug therapy.
