Depression - University of Louisiana at Lafayette by zhouwenjuan

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									            PSYCHIATRY TELEHEALTH, LIAISON & CONSULTS
                           (PSYCH TLC)




              Depression in Children and Adolescents




                               Written and reviewed:

                                    Juan Castro, M.D
                                  Assistant Professor
                               Department of Psychiatry
                      University of Arkansas for Medical Sciences




Work submitted by Contract #4600016732 from the Division of Medical Services, Arkansas
                            Department of Human Services


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                         Phone: 501-526-7425 or 1-866-273-3835




The free Child Psychiatry Telemedicine, Liaison & Consult (Psych TLC) service is available
                                           for:

       •   Consultation on psychiatric medication related issues
       •   Advice on initial management of a patient
       •   Medication titration
       •   Side effects questions
       •   Questions on combinations of medications
       •   Consultation regarding children with mental health related issues
       •   Psychiatric evaluations in special cases via Televideo
       •   Educational opportunities



This service is free to all Arkansas physicians caring for children. Telephone consults are
made within 15 minutes of placing the call and can be accomplished while the child and/or
parent are still in the office.




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                                     Table of Contents

1.   Types of Depression in Children and Adolescents

     1.1 Severity of Depression

2.   Epidemiology

3.   Etiology/Risk Factors

4.   Assessment and Diagnosis

     4.1 Screening

5.   Differential diagnosis

     5.1 Associated Disorders

     5.2 Bipolar Disorder

     5.3 Medical conditions

6.   Clinical Course

     6.1 Red Flags

7.   Treatment Recommendations

     Clinical assessment flowchart

     Clinical management flowchart

8.   What to do after starting antidepressants

9.   Bibliography




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1. Types of Depression in Children and Adolescents

   Case 1: Major Depressive Disorder

   A 14-year-old boy is brought to your office by his parents, who report that he has lost weight. They
   add that he has had very little appetite for the past month and that he is so weak that “it is very hard to
   wake him in the mornings to go to school.” You speak to the boy in private and he reports that he has
   very little energy most of the time, causing concentration problems in school. He also informs you
   that he can’t sleep. “Doctor, everything seems to be a problem in my life I have nothing to look
   forward to and sometimes I wish I was dead.”

   To be considered clinically depressed, a child or adolescent must have at least two weeks of persistent
   change in mood manifested by either depressed or irritable mood and/or loss of interest and pleasure
   plus a group of other symptoms including wishing to be dead, suicidal ideation or attempts; increased
   or decreased appetite, weight, or sleep; and decreased activity, concentration, energy, or self-worth or
   exaggerated guilt (American Psychiatric Association, 2000b; World Health Organization, 1992).

   Case 2: Dysthymia

   A 16-year-old adolescent girl is brought by her mother to your office. The patient reports being
   fatigued at times and having issues with her self esteem. She denies having suicidal thoughts, appetite
   problems or sleep disturbances. Her fatigue started at least a year ago. Her mother adds that “she has
   become very irritable and cranky this year. I don’t know what’s gotten into her.”

   For a DSM-IV diagnosis of dysthymia, a child must have depressed mood or irritability on most days
   for most of the day for a period of one year, as well as two other symptoms from a group that includes
   changes in appetite or weight and changes in sleep; problems with decision making or concentration;
   and low self esteem, energy and hope (American Psychiatric Association, 2000b).

   Case 3: Depressive Disorder NOS (Not Otherwise Specified)

   A 10-year-old boy in fifth grade is brought to your office by his parents. He reportedly has been very
   irritable, oppositional at school, clingy and crying about “little things at home.” He is making good
   grades but frequently appears to be distracted. He is sleeping and eating well.

       Also called sub-syndromal depression, Depressive Disorder, NOS is diagnosed in the presence of
   depressed mood, anhedonia (inability to experience pleasure), or irritability, and up to three
   symptoms of major depression.




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      1.1       Severity of Depression

      In both the DSM-IV-TR and the ICD-10, severity of depressive episodes is based on the number,
      type and severity of symptoms, as well as the degree of functional impairment. The DSM-IV-TR
      guidelines are summarized in the table below.



                           DSM-IV Guidelines for Grading Severity Depression

                Category               Mild              Moderate             Severe

            Number of
                                        5-6                  *                “most”
            symptoms

            Severity of
                                       Mild                  *                 Severe
            symptoms

                                 Mild impairment
            Degree of                or normal                               “Clear-cut,
            functional            functioning but            *               observable
            impairment           with “substantial                           disability”
                                and unusual” effort

            * According to the DSM-IV-TR, Moderate episode of depression “have a
            severity that is intermediate between mild and severe.”




      This website was used with permission of the REACH Institute, www.TheReachInstitute.org

2. Epidemiology
      •     Major depression in adolescents is recognized as a serious psychiatric illness with extensive
            acute and chronic morbidity and mortality. The prevalence rate is estimated to be 6 to 8
            percent, and depression is associated with a recurrence rate of 60 to 80 percent by the end of
            adolescence. Research shows that only 50 percent of adolescents with depression are
            diagnosed before reaching adulthood. Even when diagnosed, only half of these cases are
            treated appropriately.
      •     70 percent of children with a single major depressive episode will experience a recurrence
            within five years (Birmaher et al., 1996a).
      •     Lifetime prevalence by the end of adolescence is 20 percent.
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      •   At the onset of puberty there is a 3 to1 female predominance.
      •   Anxiety is often associated with depression.
      •   Suicidal thoughts are common in depressed youth.
      •   Depression marks significant risks for recurrence, substance abuse, teen pregnancy.
      •   Depression is often co-morbid (co-occurs) with other psychiatric disorders; most frequently
          anxiety disorders.

3. Etiology/Risk Factors

      •   Genetic:
      •   Vulnerability to depression is an inherited trait, i.e., depression runs in families
      •   Monozygotic twins have demonstrated higher rates of depression than in dyzigotic twins.

      •   Cognitive factors:
      •   Negative view of self, future and the world.

      •   Familial/environmental:
      •   Parental depression also affects children by modeling cognitive distortions
      •   Family discord
      •   Parental substance abuse or criminality
      •   Neglect and child maltreatment (especially sexual abuse)
      •   Bereavement due to loss of a sibling or parent




4. Assessment and Diagnosis

   Typical Clinical Presentations of Depression in Children

      Infants
      •   Failure to thrive, speech and motor delays, decrease in interactiveness, poor attachment
      •   Repetitive self-soothing behaviors, withdrawal from social contact
      •   Loss of previous/ learned skills, i.e., self-soothing skills, toilet learning

   EaEarly Childhood
      •   Loss of learned skills, temper tantrums, irritability, destructive behaviors, separation anxiety

      Middle Childhood and Adolescents

      •   Somatic complaints, school refusal, anxiety related issues, Mood-congruent hallucinations
          (rare), depressed mood (what child reports) and/or affect (non-verbal communication), self
          esteem issues, boredom, apathy, substance use, change in weight, appetite changes, insomnia,
          excessive sleep, aggression/anti-social behavior, suicidal thoughts, self injurious behaviors.


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4.1 Screening

Using screening tools can help you to increase your diagnostic impression. However, a full
evaluation for the child and family is required for a proper diagnosis.

The Center for Epidemiological Studies Depression Scale for Children (CES-DC) is an easy-to-
use assessment scale for children and adolescents. It is provided below or at:

http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf

The PHQ-9 is a well-validated tool used to assess adult depression in primary care. For a clinical
adolescent depression, the PHQ-9 was modified to better represent DSM-IV adolescent
depression and to include questions on suicide attempts and adolescent dysthymia. These
modifications have not been validated in a research setting. This scale is also provided below

Other screening tools

        •   Columbia Depression Scale (Teen Version)
        •   Kutcher Adolescent Depression Scale – 6-item
        •   PHQ-9: Modified for Teens
        •   Parent Reports: Columbia Depression Scale (Parent Version)
            (This tool can be found at Glad pc materials )




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This table was used with permission of the REACH Institute, www.TheReachInstitute.org

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                                Scoring the PHQ-9 modified for Teens

Scoring the PHQ-9 modified for teens is easy but involves thinking about several different aspects of
depression.

To use the PHQ-9 as a diagnostic aid for Major Depressive Disorder:
    • Questions 1 and/or 2 need to be endorsed as a “2” or “3”
    • Need five or more positive symptoms (positive is defined by a “2” or “3” in questions 1-8 and by
        a “1”, “2”, or”3” in question 9).
    • The functional impairment question (How difficult….) needs to be rated at least as “somewhat
        difficult.”

To use the PHQ-9 to screen for all types of depression or other mental illness:
    • All positive answers ( positive is defined by a “2” or “3” in questions 1-8 and by a “1”, ‘2”, or
        “3” in question 9) should be followed up by interview
    • A total PHQ-9 score ≥10 (see below for instructions on how to obtain a total score) has a good
        sensitivity and specificity for MDD.

To use the PHQ-9 to aid in the diagnosis of dysthymia:
    • The dysthymia question (In the past year…) should be endorsed as “yes.”

To use the PHQ-9 to screen for suicide risk:
    • All positive answers to question 9 as well as the two additional suicide items MUST be followed
        up by a clinical interview.

To use the PHQ-9 to obtain a total score and assess depressive severity:
    • Add up the numbers endorsed for questions 1-9 and obtain a total score.
    • See Table below:

        Total Score           Depression Severity

        0-4                   No or Minimal depression

        5-9                   Mild depression

        10-14                 Moderate depression

        15-19                 Moderately severe depression

        20-27                 Severe depression



This table was used with permission of the REACH Institute, www.TheReachInstitute.org


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5.   Differential Diagnosis

     The differential diagnosis for suspected depression in children and adolescents include:

     •   Normal moodiness of teens
     •   Substance induced mood disorder
     •   Adjustment disorder with depressed mood
     •   Adjustment disorder with depressed mood and anxiety
     •   Anxiety disorders
     •   Post Traumatic Stress Disorder
     •   Depressive episode of Bipolar Disorder
     •   Eating Disorder
     •   Attention Deficit Hyperactivity Disorder
     •   Conduct Disorder


     5.1 Associated Disorders

     A number of associated disorders commonly co-occur with depression in children and
     adolescents. These include:

     •   Anxiety disorders: 30 to 80 percent
     •   Substance abuse: 20 to 30 percent
     •   Disruptive disorders (including oppositional defiant disorder and conduct disorder):
         10 to 80 percent
     •   Somatoform disorders (physical complaint not fully explained by another medical condition
         or mental disorder

     5.2 Bipolar Disorder

     Along with ruling out normal mood changes of adolescence which is generally not associated
     with a decline in functioning (i.e., drop in grades), clinicians should assess for symptoms of
     bipolar disorder. Bipolar disorder is less common in teens than adults. In addition, many teens
     that may eventually have bipolar disorder will be presenting first with a depressive episode in
     adolescence and thus diagnosing bipolar disorder at this point will not be possible.

     Bipolar Disorder Symptoms

     Middle Childhood

     •   Persistently irritable mood is described more than euphoric mood.
     •   Aggressive and uncontrollable outbursts, agitated behaviors (may look like attention deficit
         hyperactivity disorder [ADHD] with severe hyperactivity and impulsivity) .
     •   Attention Deficit Hyperactivity Disorder
     •   Extreme fluctuations in mood that can occur on the same day or over the course of days or
         weeks.
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       •   Reckless behaviors, dangerous play, inappropriate sexual behaviors.

       Adolescence

       •   Markedly labile mood
       •   Agitated behaviors, pressured speech, racing thoughts, sleep disturbances
       •   Reckless behaviors (i.e., dangerous driving, substance abuse, sexual indiscretions)
       •   Illicit activities (i.e., impulsive stealing, fighting), spending sprees.
       •   Psychotic symptoms (i.e., hallucinations, delusions, irrational thoughts)

   If during your evaluation of depression you rule out depression but the patient has another mental
   health illness, please refer to other treatment guidelines in this series for treatment recommendations
   or consult the Child Psychiatry Telephone Service at 501-526-7425 or 1-866-273-3835 for
   assistance.

       5.3 There are also some medical conditions that can mimic a depressive episode:

       •   Hypothyroidism
       •   Anemia
       •   Mononucleosis
       •   Premenstrual syndrome
       •   Chronic fatigue syndrome
       •   Autoimmune diseases
       •   Medications (corticosteroids, contraceptives, stimulants)

6. Clinical Course

   •   Most children recover from their first depressive episode.
   •   Recurrence is common in patients who suffer from depression.
   •   Some studies have shown that a substantial proportion will have depression as adults.
   •   At least 30 percent of children with a depressive episode will develop bipolar disorder.

       6.1 Red Flags
           •   Patients reporting auditory or visual hallucinations.
           •   Patients who have suicidal ideation, thoughts or attempts.
           •   Patients with poor parental supervision or family support.
           •   Patients with poor functioning in multiple areas of his/her life (school, social and family
               life).
           •   Psychotic or bipolar disorder.
           •   If any of these are present, then referral to a child psychiatrist is indicated.




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         6.2 Complications
             •   Depression hinders development of the child’s emotional, cognitive, and social skills.
             •   May interfere considerably with family relationships.
             •   Suicide attempts and completion are among the most significant and devastating
                 sequelae.
             •   Children and adolescents with depressive disorders are also at high risk of substance
                 abuse (including nicotine dependence), legal problems, exposure to negative life events,
                 physical illness, early pregnancy, and poor work, academic, and psychosocial
                 functioning.

7.     Treatment: The following treatment recommendations were used with permission
       from the REACH institute, www.TheReachInstitute.org

Recommendation 1

Patients with depression risk factors (such as history of previous episodes, family history, other
psychiatric disorders, substance abuse, trauma, psychosocial adversity, etc.) should be identified and
systematically monitored over time for the development of a depressive disorder.

Recommendation 2

Assessment for depression should include direct interviews with the patient and his/her family/caregiver
and should include the assessment of functional impairment in different domains.

Clinicians should educate and counsel families and patients about depression and options for the
management of the disorder.

•    Recognize that disclosing painful feelings is often distressing for a child or adolescent.

• Consider following up assessment questions with empathic responses such as, “I’m really glad you
were able to tell me about how you feel, even though it’s not easy. You’re telling me means that we can
work together to find ways to help you feel better.”

• Encourage the child or adolescent to participate in activities that improve his self-esteem and sense of
mastery (i.e., encourage a child or adolescent who likes to draw to take an art class).

• Discuss the importance of a healthy lifestyle (i.e., participating in regular physical activity, eating
healthy foods) in maintaining a sense of well-being. In particular, regular physical activity can have a
beneficial impact on depressed mood (Tkachuk and Martin, 1999) and should be discussed as an important
element in any comprehensive treatment plan for adolescents with depressive symptoms.

• Encourage the child or adolescent to interact with peers in a supportive environment (i.e., during
after-school activities, in clubs or sports, at play dates [for younger children], through faith-based
activities).
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• The child or adolescent should be assessed, and appropriate modifications should be made for a child
or adolescent with a learning disorder or school difficulties that may be contributing to their sense of
failure.

• Collaborate with the school team to ensure that academic expectations and the level of services are
appropriate for the child or adolescent’s needs and abilities. School based professionals such as school
nurses, school social workers, school psychologists, guidance counselors, and teachers should be involved
in the child’s or adolescent’s treatment plan.

• Clinicians should develop a treatment plan with patients and families and set specific treatment goals
in key areas of functioning including home, peer, and school settings.

Recommendation 3

The PC clinician should establish relevant links/collaboration with mental health resources in the
community, which may include patients and families who have dealt with adolescent depression and are
willing to serve as resources to other affected adolescents and their family members.

Recommendation 4

•   All management must include the establishment of a safety plan which includes:

    •   Restricting lethal means (weapons, poisons at home)
    •   Engaging a concerned third-party (caretakers)
    •   An emergency communication mechanism should the patient deteriorate, become
        actively suicidal or dangerous to others, or experience an acute crisis associated with
        psychosocial stressors especially during the period of initial treatment when safety
        concerns are highest.


After initial diagnosis, in cases of mild depression, clinicians should consider a period of active
support and monitoring before starting other evidence-based treatment

If clinician identifies an adolescent with moderate or severe depression or complicating factors/conditions
such as co-existing substance abuse or psychosis, consultation with a mental health specialist should be
considered. Appropriate roles and responsibilities for ongoing management by the primary care physician
and mental health clinicians should be communicated and agreed upon. The patient and family should be
consulted and approve the roles of the primary care physician and mental health professionals.




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This table was used with permission of the REACH Institute, www.TheReachInstitute.org



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Treatment

For children and adolescents who do not respond to supportive psychotherapy or who have more
complicated depressions, a trial with a specific type of psychotherapy and/or antidepressant is indicated.

        •   Treatment should be reassessed every six weeks and continued for 6 to 12 months.

Treatment options

        •   Psychotherapy
               - Cognitive behavioral therapy
               - Interpersonal therapy

        •   Medications
               - Selective serotonin reuptake inhibitors
               - Serotonin reuptake inhibitors
               - Monoamine oxidase inhibitor
               - Tricyclics
               - Medication Treatment

        •   Different psychotherapy approaches may help in mild and moderate cases of depression and
            should be the first treatment.

        •   Fluoxetine in combination with Cognitive Behavioral Therapy has best evidence of success
            (Marsh et al,. 2004 and 2007).

FDA Approved Antidepressants in Children

        - Fluoxetine: Children: 5 to 60 mg/day in a single daily dose

                - Adolescents 13 and up: 20-60mg a day in a single daily dosing

        - Escitalopram >12y/o for treatment of depression. 5-20mg in a single daily dosing.

Antidepressants used off-label in children and adolescents

        •   Sertraline: Ages 6 to 12: 25mg/day in single daily dosing

                - Ages 13 and up: 25-200mg in single daily dosing

        •   Fluvoxamine:
                - Ages 8 to 17: initial dose 25mg at bedtime; increase by 25mg every week.
                   Maximum dose: 200mg. Doses over 50mg should be divided in 2 doses with larger
                   dose being administered at bedtime.

        •   Citalopram: Ages 6 to 12: 10mg.
                    - Ages 13 and up: 10-40mg. Max dose: 40mg
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SSRI/SNRI Adverse Effects

Serious Adverse Effects

        •    Serotonin Syndrome (Excess serotonin): Increased heart rate, sweating, high blood pressure.
        •    Akathisia: Discomfort, tension, insomnia, motor restlessness, marked anxiety and panic)
        •    Hypomania: Grandiosity, excess energy, pressure speech.
        •    Discontinuation syndromes: After discontinuation or dose reduction. Symptoms are variable,
             i.e., dizziness, electric shock-like sensation, sweating.


Common Adverse Effects

        •    GI effects (dry mouth, constipation, diarrhea)
        •    Sleep disturbance (insomnia or hypersomnia)
        •    Irritability
        •    Disinhibition: Non specific behavioral activation such as silliness, aggression, insomnia
             and irritability.
        •    Agitation/jitteriness
        •    Headache



When to use a different Antidepressant:

A different antidepressant should be used when the maximum dose is reached and maintained for four to
six weeks without response in target symptoms or there are major side effects with the medication.

If one or two trials of an antidepressant fail, refer the patient to a psychiatrist or call Psych TLC for a brief
telephone consultation at 501-526-7425 or 1-866-273-3835.




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        This table was used with permission of the REACH Institute, www.TheReachInstitute.org




8. What to do after starting an antidepressant

• A small but statistically significant increase in suicidal thoughts appears in clinical trials of
antidepressants in children. Subsequent screening for suicidal thoughts after starting antidepressants is
recommended.

• Suicide risk and assessment plan should be documented.
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Screening for Suicide

•   Have you had thoughts of hurting yourself?
•   Have you ever tried to hurt yourself?
•   Have you ever wished you were not alive?
•   Have you had thoughts of taking your life?
•   Have you done things that are so dangerous that you knew you might get hurt or die?
•   Have you ever tried to kill yourself?
•   Have you had recent thoughts of killing yourself?
•   Do you have a plan to kill yourself?
•   Are the methods to kill yourself available to you?
•   Do you have access to guns?


Take these points with you

•   Depression and anxiety are common and at times co-occur in children and adolescents
•   Earlier awareness/intervention may prevent negative events
•   Screening tools are available, easy to use, and facilitate recognition
•   Practice guidelines and recent evidence should inform treatment decisions
•   Counseling can help define diagnosis and is a first-line treatment
•   Always do suicide screening on your patients


If your patient is suicidal or you have questions about the safety of the patient, please refer the
patient to the nearest emergency room for a thorough evaluation.

•   You may also call Psych TLC at 501-526-7425 or 1-866-273-3835 for a free, brief telephone
    consultation for your patient.




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Bibliography

American Psychiatric Association (2000b), Diagnostic and Statistical Manual
      of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington,
      DC: American Psychiatric Association.

American Academy of Child and Adolescent Psychiatry: Guidelines for treatment of Depression.
       Treatment guidelines for depression in Adolescents (GLAD-PC materials). Retrieved from
       http://www.thereachinstitute.org/files/documents/GLAD-PCToolkit.pdf.

Birmaher B, Ryan ND, Williamson DE et al. (1996), Childhood and adolescent depression: a
       review of the past 10 years. Part I. J American Academy of Child and Adolescent
      Psychiatry 35:1427-1439.

Bezchlibnyk-Butler, K.Z, & Virani, A.S.(Eds) (2004). Clinical handbook of psychotropic drugs for
       children and adolescents, antidepressants. Hogrefe & Huber: 26-82.

Jellinek M, Patel BP, Froehle MC, eds. 2002. Bright Futures in Practice: Mental Health—Volume I.
         Practice Guide. Arlington, VA: National Center for Education in Maternal and Child Health.
         Retrieved from http://www.brightfutures.org/mentalhealth/pdf/bridges/mood_dsrdr.pdf

March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. Fluoxetine, cognitive behavior
       therapy and their combination for adolescents with depression: treatment for adolescents
       with depression study (TADS) randomized controlled trial. JAMA 2004; 292:807-20.

March JS, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. The Treatment for Adolescents
       with Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen
       Psychiatry 2007; 64: 1132-43.




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