Pediatric Annals

Healthy Baby/Healthy Child 

Depression in Children and Adolescents: The Pediatrician at the Front Lines

Rachel S. Dawson, DO, MPH, FAAP

Abstract

Pediatricians are the primary care providers for most children and adolescents in the United States, so they need to feel comfortable caring for children and teens with depression. This topic is an extremely important one because the top three reasons teens die or get injured are related to accidents (3.7 per 100,000 for those ages 5–14 years and 28.5 per 100,000 for those ages 15–24 years), suicide (1 per 100,000 in the younger age group, and 12.5 deaths per 100,000 in those ages 5–14 years), and homicide (0.7 per 100,000 in those age 5–14 years, and 10.8 per 100,000 in those age 15–24 years). Each year, 21% of children ages 9 to 17 years are diagnosed with a mental or addictive disorder associated with at least minimum impairment, with 11% of these children having significant functional impairment and another 5% demonstrating extreme functional impairment. We know that one-half of all lifetime cases of mental health disorders start by age 14 years. This includes serious adult psychiatric illnesses such as major depressive disorder, anxiety disorders, and substance abuse. Three-quarters are present by age 24 years; therefore, interventions aimed at prevention or early treatment need to focus on youth. [Pediatr Ann. 2018;47(7):e261–e265.]

Abstract

Pediatricians are the primary care providers for most children and adolescents in the United States, so they need to feel comfortable caring for children and teens with depression. This topic is an extremely important one because the top three reasons teens die or get injured are related to accidents (3.7 per 100,000 for those ages 5–14 years and 28.5 per 100,000 for those ages 15–24 years), suicide (1 per 100,000 in the younger age group, and 12.5 deaths per 100,000 in those ages 5–14 years), and homicide (0.7 per 100,000 in those age 5–14 years, and 10.8 per 100,000 in those age 15–24 years). Each year, 21% of children ages 9 to 17 years are diagnosed with a mental or addictive disorder associated with at least minimum impairment, with 11% of these children having significant functional impairment and another 5% demonstrating extreme functional impairment. We know that one-half of all lifetime cases of mental health disorders start by age 14 years. This includes serious adult psychiatric illnesses such as major depressive disorder, anxiety disorders, and substance abuse. Three-quarters are present by age 24 years; therefore, interventions aimed at prevention or early treatment need to focus on youth. [Pediatr Ann. 2018;47(7):e261–e265.]

At any one time, 10% to 15% of children and adolescents have some symptoms of depression. The prevalence of major depressive disorder (MDD) is 5% in children age 9 to 17 years. MDD tends to last 7 to 9 months, with 20% to 40% of patients relapsing within 2 years, and 70% by adulthood.1

Depression is present in 1% of prepubescent adolescents, and in 8% to 10% of older adolescents, which is close to prevalence rates in adults.1 Girls are twice as likely to demonstrate clinical depression as boys.2

The national Youth Risk Behavior Surveillance study (YRBS) monitors health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and adolescents in the United States.3 The national YRBS is conducted every 2 years, providing data representative of 9th to 12th grade students in public and private schools throughout the United States; however, the survey excludes youth who are incarcerated, homeschooled, or not in school.3

The most recent report showed that 29% of students (up from 26% from prior report3 felt so sad or hopeless most days for at least 2 weeks that they stopped doing some of their usual behaviors or activities: 17% (up from 14%) seriously considered suicide in the previous 12 months, 14% (up from 11%) made a suicide plan, and 8.6 % (up from 6.3%) attempted suicide. There is strong evidence that more than 90% of children and adolescents who commit suicide have a mental disorder.3

It is also known that approximately two-thirds of children with MDD also have another mental disorder.3 The most common comorbid conditions are dysthymia, anxiety, disruptive disorder, and substance abuse disorder.1

Outcomes of Depression in Children and Adolescents

Depression leads to many other issues such as personal distress, having fewer friends and sources of support, missed educational and job opportunities, a 5-fold increased risk of suicide attempt, increased somatic symptoms such as stomachaches and headaches, reduced social functioning, deteriorating school performance, increased risk for drug and alcohol use, and nicotine dependence.4,5

Adolescents visit their primary care provider approximately 2 or 3 times per year, and adolescents with mental health issues are more likely than their nonaffected peers to be high users of primary care services.6

Primary care is a setting in which parents and adolescents feel relatively comfortable disclosing mental health issues. Therefore, a strong positive relationship with their physician can be a motivator of many different types of change, even in the absence of medication.7

Simple Screening Tool

Using the well-known acronym D-SIGECAPS will help providers determine the severity of their patients' depression. The symptoms associated with depression include Depressed mood, decreased Sleep and insomnia with awakening at 2–4 am, decreased Interest in activities (anhedonia), feelings of Guilt or worthlessness, decreased Energy, difficulties with Concentration, Appetite disturbance or weight loss, Psychomotor retardation or agitation, and finally, Suicidal thoughts.5 If a child or adolescent has least 5 of 9 positive answers every day for 2 weeks, this signifies depression.5

Risk Factors Associated with Depression in Children and Adolescents

There are proximal risk factors occurring immediately or shortly before the onset of the episode of depression. These may include anxiety disorders such as panic disorder and social anxiety disorder.2 A medical condition such as diabetes or cancer also can be proximally associated with depression.2

There are other distal risk factors that can occur before the onset of the depression episode, such as a family history of MDD or bipolar disorder, early and prolonged sexual or physical abuse, and early death of a parent.2

Risk Factors Associated with Suicide in Children and Adolescents

Other risk factors to consider include history of co-occurring mental disorder and substance abuse disorder (>90%), prior suicide attempts (with at least one-third of victims having made previous attempts), and male gender (boys and men who have attempted suicide previously are 30 times more likely to complete it than someone who has never attempted).5 It is also important to assess intention to commit suicide as well as mode, location, and likelihood of rescue.2

When taking the patient's history, other potential concerns to be aware of include history of suicide attempts or completed suicides among first- or second-degree relatives, and prior physical and/or sexual abuse. Children who run away from home and homeless youth are particularly vulnerable.2 Having a family history of mental and substance abuse disorders, especially in parents, is strongly correlated with mental health problems in children and adolescents. A history of parental conflict, stressful life events, or loss should also be considered.2

Suicide contagion accounts for approximately 1% to 5% of all teen suicides, and this usually occurs soon after highly publicized suicides of teenagers and popular young adults.5

Having easy access to firearms also increases the risk of suicide. Fifty percent of completed suicides in people age 15 to 24 years were carried out with a firearm.5 If a firearm is in the home, there is a 31- to 108-fold increase in completed adolescent suicide even in the absence of clear psychiatric illness.5

Substance Abuse and its Association with Mental Health Concerns

Approximately 41% to 65% of people with a lifetime substance use disorder also have a lifetime history of one or more mental health disorders, with rates being highest in those age 15 to 24 years.6 According to the YRBS, 63% (down from 73%) of all teens surveyed have a history of lifetime alcohol use, 32.8% (down from 42%), had at least one drink in the previous 30 days, 17% (down from 24%) had five or more drinks at least once in the previous 30 days, 17% (down from 21%) had more than a few sips of alcohol before age 13 years, and 9.7% had driven a car after drinking alcohol in the previous 30 days.1

For marijuana use, 38% of teens age 13 to 18 years have a history of lifetime use, with 21% having used it at least once in the previous 30 days, 7.5% have tried marijuana before age 13 years, 7% (down from 11.7%) have a history of lifetime inhalant use, 16% (down from 20%) used prescription drugs, 5% (down from 6.4%) have history of lifetime cocaine use, 3% (down from 4.1%) have a history of lifetime methamphetamine use, and 2% have history of lifetime intravenous (IV) drug use.1

Substance abuse can be a function of psychologic and biologic factors. For example, some children and adolescents use drugs to help coping with stressful day-to-day activities. Some children fear consequences of withdrawal from drugs, some have an addictive personality, and there are others with a genetic predisposition to drug use.

It is estimated that there are 8 to 25 suicide attempts per completed suicide, with 6 times as many boys and men dying by suicide, but girls and women attempt suicide more often (a ratio of 4 to 1).5 The YRBS does not show parallel decline in attempts to actual completion of suicides.

These numbers speak for themselves. There is a huge shortage of mental health clinicians and there are barriers to children's access to mental health services, which means that primary care clinicians need to learn how to manage depression.

Diagnostic Criteria for MDD

The Diagnostic and Statistical Manual for Mental Disorders, fifth edition8 states that MDD symptoms must cause clinically significant distress or impairment of social, occupational, or other important areas of functioning and cannot be due to direct physiologic effect of a substance such as a drug of abuse or medication; it also states that symptoms are not better accounted for by bereavement.8

It is important to recognize and understand bipolar disorder so that the health care provider may know when to refer a patient for more specialized care. This disorder is characterized by periods of depressed mood and periods of significantly elevated mood, known as mania.8 Mania is characterized by intense energy, hyperactivity, elation, grandiosity, sleeplessness, racing thoughts, pressured speech, excessive risk-taking and impulsive behaviors, and hypersexuality in some.8

There is no clear way of predicting which teens who present with MDD will develop bipolar disorder. Some risk factors may include rapid onset of MDD, psychotic symptoms occurring together with MDD, and family history of bipolar disorder.8 Treatment with antidepressants may trigger mania;8 therefore, it is important to rule out this condition through screening.

Dysthymia is represented by depressed or irritable mood for most of the day, on most days, for at least 1 year. Two or more of the following must also be present: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.8

These symptoms often occur concurrently with adolescent depression and are not necessarily predictive of future onset of adolescent depression. This may involve family conflict with poor affective involvement and significant communication difficulties, as well as exposure to significant negative life events.

Negative life events are commonly, but often mistakenly, considered to be causal risk factors for adolescent depression. However, these events are so common in adolescents that, if they were causal, would cause every teen to be clinically depressed. These events can lead to distress and depressive symptoms, but they are unlikely to be single substantive causal factors for MDD.

History of Progression

Depressive disorders typically do not have a sudden onset. They tend to be gradual, with an insidious onset that might be overlooked. Gradual onset of depression, especially when not identified as such, can lead to significant life events such as interpersonal problems, family and school issues, and breakups of romantic relationships.

There are special populations, such as lesbian, gay, bisexual, and transgender (LGBT) adolescents, who experience higher rates of depression. In particular, teens and men who are homosexual are 4 times more likely to attempt suicide than their heterosexual peers.5

How can a Pediatrician Identify Depression in Children and Adolescents?

It is challenging to identify children and youth with depression because patients may present with marked irritability or boredom rather than sad or depressed mood. Children and adolescents are hesitant to self-disclose symptoms if not directly asked, and there are no diagnostic or laboratory tests to establish the diagnosis, so a careful history and physical examination is critical. One should also look for evidence of self-injurious behavior. Appropriate laboratory work should be based on the history and physical examination; thyroid testing should be considered if appropriate.

For children and adolescents with suicidal ideation, ask about the frequency of those thoughts, if there is a plan in place, motivation to commit suicide, and access to methods that could lead to a completed suicide such as firearms and dangerous medications. Look into life stressors that precipitated the thoughts, any history of substance abuse, and history of prior attempts. Providers should admit patients to a hospital if any questions arise about the patient's safety.

Treatment of Depression in Children and Adolescents

There is evidence-based treatment for depression in children and adolescents. Selective serotonin reuptake inhibitors (SSRI) are known to be effective.7 Other treatment includes psychological treatments such as cognitive-behavioral therapy (CBT) and interpersonal therapy.7

CBT involves dealing with how thoughts influence behaviors and feelings and vice versa. CBT treatment targets a patient's thoughts and behaviors to improve his or her mood, leading to increase in pleasurable activities, which is called behavioral activation.7 Other goals include reducing negative thoughts with cognitive restructuring, and improving assertiveness and problem-solving skills with the goal of reducing feelings of hopelessness.7 These sessions may include the parent or caregiver of the child or adolescent.7

Interpersonal therapy works on how interpersonal problems may cause or exacerbate depression.7 Treatment targets a patient's interpersonal problems to improve interpersonal functioning and mood. Patients identify interpersonal problem areas, improving interpersonal problem-solving skills and modifying communication patterns. This will also involve parents and caregivers during specific phases of therapy.7

Approach to mild depression is started with watchful monitoring after psychotherapy. It may also be helpful to include regular telephone calls, face-to-face visits, and supportive problem-based counseling visits. It is critical to include continuous evaluation of suicidality, and if no substantive improvement is noted in 4 to 6 weeks, intensive medical and psychological intervention may be indicated.7

The approach to moderate and severe depression requires immediate initiation of medication and/or psychological intervention. Ongoing monitoring of suicidality needs to be part of the visits, and addressing issues of substance abuse and dependence needs to be discussed. Immediate referral to psychiatry and perhaps hospitalization may be important early on in these cases. If psychotic symptoms or suicidal intent or actions are noted, immediate admission is mandatory.7

Evidence points to fluoxetine as the single best intervention, with fluoxetine plus CBT as the best overall intervention.7 Regardless of intervention, placebo response rates range from 35% to 50% in most cases.7

Medications: Mode of Action, Advantages, and Disadvantages

SSRIs block reuptake of serotonin in presynaptic neurons, and the dose for adolescents is similar to adults. The safety of SSRIs is established and their use has not been associated with an increased risk of completed suicide.7,8 Compared to placebo, there is an increase in suicidal ideation and self-harm behaviors, which is discussed in a black box warning.7,8 Providers must inform their patients about adverse effects when starting the medication.7

SSRIs have clear advantages over other depression medications, such as less sedation, less orthostatic hypotension, less dry mouth, and less blurry vision. This class does not potentiate effects of alcohol or sedative-hypnotic agents. Dosing is convenient (once daily) and with much lower risk in overdose situations. Disadvantages include inhibition of cytochrome P-450, which can lead to drug-drug interactions. Sexual dysfunction with possibility of impotency and loss of libido can reduce compliance in teens who may be sexually active. Other noted side effects are disinhibition, induction or exacerbation of suicidality, and precipitation of a hypomanic-manic episode.8

Monoamine oxidase inhibitors and tricyclic antidepressants are weak and not significantly better than placebo in adolescents. Their safety is not well-studied in adolescents. These have cardiotoxic side effects and are best not used in children and adolescents.7,8

Bupropion is a second-line medication and is a dopamine reuptake inhibitor with some norepinephrine activity.7 It has stimulant-like properties so it may benefit patients with significant psychomotor retardation. Its advantages are similar to SSRIs (with low risk in overdose), and it does not potentiate alcohol or sedatives. There is not a significant P-450 interaction associated with bupropion and it is least likely to cause sexual dysfunction. It has been demonstrated effective in smoking cessation as well. Disadvantages are that it is associated with higher risk of seizures with doses greater than 450 mg. There is also dose-dependent increase in blood pressure.7

Primary care providers should become familiar prescribing antidepressants, learning at least two or three medications well and becoming comfortable with prescribing these. Fluoxetine, citalopram, sertraline, and escitalopram are good choices with which to become familiar.7

Initiation, Maintenance, and Termination of Medications

During initiation, only prescribe the number of pills needed for the first 2 weeks of treatment. Begin with a low initiation dose starting at half the manufacturer's recommended dose and increase it gradually over 6 to 8 weeks to initial target dose. Continually assess for side effects and remember that the placebo effect is common.

Make sure to counsel patients and parents on expected length of time for improvement, as it takes at least 6 to 8 weeks to reach initial target dose. Remission may occur in 8 to 12 weeks. Primary care providers should maintain open lines of communication and make joint decisions to ensure compliance. Continue to monitor behavioral and somatic adverse side effects and discuss progress of psychotherapy and counseling. Review the treatment plan at every visit, and if no progress is noted then consider dose increases as appropriate. It may be necessary to switch antidepressants or provide psychiatry referral.

Antidepressants should not be stopped abruptly (with the exception of fluoxetine due to its long half-life). Sudden stopping may lead to withdrawal syndrome, which includes dizziness, weakness, nausea, tremor, headaches, anxiety, and insomnia. Consider stopping approximately 6 to 9 months after remission of symptoms and taper the dosage no more than 25% per week. It can be discontinued over a period of 2 to 3 months. It is important that patients and guardians are taught to monitor for recurrence of depressive symptoms during the tapering and discontinuation period. Patients should be seen every 2 to 4 months during this period. If depression recurs, prompt treatment of previously effective medication should be reinitiated.

Conclusion

Child and adolescent depression is a significant public health problem and there is a high degree of morbidity and mortality associated with it. Pediatricians should know the risk factors for depression and suicide. Pediatricians need to ask the tough questions, know what matters to teens the most, be nonjudgmental in their approach, and encourage change for risk-taking behaviors when possible. Effective treatments are available and can be initiated in the primary care setting. Ongoing and careful monitoring of therapeutic effectiveness and adverse events in the context of a supportive relationship with medical providers and family is important and effective. SSRIs are safe and effective in treating depression, with psychological counseling being a useful adjunct. I encourage all child health care providers to boldly screen children and adolescents with depression and treat accordingly.

References

  1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Mental health surveillance among children–United States, 2005–2011. https://www.cdc.gov/mmwr/pdf/other/su6202.pdf. Published May 17, 2013. Accessed June 19, 2018.
  2. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque DGLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081. doi:. doi:10.1542/peds.2017-4081 [CrossRef]
  3. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2015. MMWR Surveill Summ. 2016;65(No. SS-6):1–174. doi: http://dx.doi.org/10.15585/mmwr.ss6506a1.
  4. Chun TH, Mace SE, Katz ERAmerican Academy of PediatricsCommittee on Pediatric Emergency Medicine, and American College of Emergency PhysiciansPediatric Emergency Medicine Committee. Evaluation and management of children with acute mental health or behavioral problems. Part II: recognition of clinically challenging mental health related conditions presenting with medical or uncertain symptoms. Pediatrics. 2016;138(3):e20161573. doi:. doi:10.1542/peds.2016-1573 [CrossRef]
  5. Shain BCommittee on Adolescence. Suicide and suicide attempts in adolescents. Pediatrics. 2016;138(1):e20161420. doi:. doi:10.1542/peds.2016-1420 [CrossRef]
  6. Chun TH, Mace SE, Katz ERAmerican Academy of PediatricsCommittee on Pediatric Emergency Medicine, and American College of Emergency PhysiciansPediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral problems. Part I: common clinical challenges of patients with mental health and/or behavioral emergencies. Pediatrics. 2016;138(3):e20161579. doi:10.1542/peds.2016-1570 [CrossRef].
  7. Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REKGLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): part II. Treatment and ongoing management. Pediatrics. 2018;141(3):e20174082. doi:. doi:10.1542/peds.2017-4082 [CrossRef]
  8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
Authors

Rachel S. Dawson, DO, MPH, FAAP

Rachel S. Dawson, DO, MPH, FAAP, is the Regional Medical Director for Vaccines, South Central Region, Merck & Co., Inc.

Address correspondence to Rachel S. Dawson, DO, MPH, FAAP, via email: rachel.dawson@merck.com.

Disclosure: Rachel S. Dawson received grants from the Pfizer Independent Grants for Learning and Change (outside of the submitted work).

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