Guidelines for the Assessment and Treatment of Major Depression In Children and Adolescents University of Louisville Depression Center
Depression in a pediatric population occurs in approximately 2% of children and 4% of teens; in just Jefferson Co. Kentucky, 2500-3000 children and teens would meet DSM-IV R criteria for Major Depression, Depression NOS, and/or Dysthymic Disorder, based on prevalence data. It is then essential to make an early and accurate diagnosis, to alleviate the acute episode, prevent any developmental impairment, and minimize chronicity and progression to adult forms of mood disorders. The symptoms of pediatric depression are similar to those occurring in adults, with the notable exceptions of more irritable and angry mood and less melancholy than found in the adult forms of the disorder; other differences reflect the significant influences of developmental traumas and pathology, and interpersonal/familial factors in exacerbating or even initiating depressive symptomatology. A child or teen may present with a notable change in functioning in one or more areas, such as academic effort and motivation, problematic peer relationships, deterioration in his ability to tolerate frustration, or with a much more reactive and labile mood. Significant somatic complaints may be part of the presentation, especially with younger children. While anger may be a predominate mood, all symptoms should be identifiable as a qualitative change from a previous stable level of functioning. Also, due to differences based on age and stage of development, as well as cognitive ability, many symptoms overlap diagnostically with other illnesses, again emphasizing the need for accurate diagnosis of all Axis I and II problems. Comorbidity is high in youth with depression: studies show 40% to 90% of children and teens can be identified as meeting criteria for another psychiatric illness, with anxiety and disruptive behavior disorders (Oppositional Defiant Disorder, Conduct Disorder, and Attention Deficit/Hyperactivity Disorder) as the most frequent, and with teenagers, substance abuse. Learning disorders should be considered whenever a school-age child or teen presents with depression; also, bullying at school has been identified as a risk factor for both depression and suicide attempt. Children and teens can be very accurate historians, but to a much greater degree than with adults, the history of symptom onset, temporal progression of symptoms, functional impairment, and family function assessment must be obtained from other sources, usually the youth’s immediate family, parents or guardians, and teachers when possible. When enough biopsychosocial data has been gathered, then DSM IV R criteria is used to make a diagnosis; formal psychological testing may be required and is recommended when the symptoms are complex or when comorbidity confounds the diagnosis. Once the diagnosis is made then the severity of functional impairment determines the immediate level of intervention. A child or teen with mild depressive symptoms of brief duration and mild functional impairment may be treated with supportive individual and family therapies and education, given adequate family psychological and financial resources. Youth with moderate to severe depression may be treated with two of the proven evidencebased therapies, CBT or IPT, or treated with antidepressant therapy; psychosis, suicidality, and lack of family resources (including poverty, crisis, or mental illness in other family members), may require more intensive therapy, to include partial hospitalization, in-home services, or psychiatric hospitalization, in an attempt to ensure immediate safety and rapid stabilization. The initial treatment plan should include the child and his legal guardians, accepting the need for confidentiality for the minor patient, and informed consent for treatment by both the patient and the legal guardian, especially when considering the use of antidepressants. Expert consensus recommends scheduled reassessment of progress every four weeks, using accepted instruments normed for teens and children, until the patient is in remission; then, the maintenance phase of treatment proceeds for an additional six to twelve month at which time the therapy could be ended, based on individual and family risk factors. Not surprisingly, comorbidity strongly affects treatment results, and because of this many times therapy must be multimodal, including school-based therapies and
accommodations, family therapy, and expressive therapies. Diet, sleep hygiene, relaxation techniques, and physical exercise should be included as adjunctive therapies. Still, the core treatments for moderate and severe depression are SRI (serotonin reuptake inhibitor) antidepressant therapy and/or the RCT (randomized control trial) proven therapies: CBT (cognitive behavioral therapy) and IPT (interpersonal therapy). IPT, especially with teens, given the developmental need to establish identity, may have additional benefits as compared to CBT, but both have been found to be very effective. Length of treatment varies, but most studies describe a minimum of 14 sessions, and then maintenance sessions specific to the patient’s needs. Medications can also be very effective, more so with teens than with children, but only fluoxetine has been FDA approved for the treatment of depressive disorders in pediatric patients. Other SRI medications are probably as effective, but unlike the benefits shown in adult studies, TCA (tricyclic antidepressant) medications have not proven to be effective for teens and children with depression. Many studies have shown that after a reasonable period of time, a poor initial response to treatment can improve with a change of therapy, such as IPT being discontinued for CBT, and with the antidepressants, changing from one medicine to another in the same class. Augmenting psychotherapy with antidepressant therapy has small but significant additive benefits, and augmenting antidepressants with mood stabilizers such as lithium, valproate, lamotrigine, other antidepressants including venlafaxine, trazadone and buproprion, buspirone and the atypical antipsychotic medications, has both theoretical and case-report benefit, and is commonly used in the community. Still, these medications with the exception of fluoxetine are given “off label”, which is of special import when given to minors, especially with the current BLACK BOX WARNING on many of these medications. Good informed consent is an essential part of the therapeutic alliance, which determines compliance with treatment, and the risk/benefit of any treatment, given such warnings, must be explained. Of note with this particular issue, the basis of the BLACK BOX WARNING, is that compared to placebo, 4% of children taking SRIs, (primarily paroxetine), developed agitation, increased suicidal ideation and attempt, versus 2% for the placebo group (but with no increase in actual completed suicide). Given that approximately 60% of completed pediatric suicides are associated with depressive disorders, and that of all RCT treatments, antidepressant therapy has shown the most protective benefits for suicide prevention, risk/benefit analysis would recommend the use of SRI medications for these cases. This again highlights some of the difficulty in caring for the child or teen with depression, where many persons and even systems may be actively involved in the therapeutic process, and legal rights and obligations may be complicated. Again, when medication is used, it should be continued for a minimum of six to twelve months after achieving remission, with clinical and hematological monitoring as recommended for the agent used.
References
American Academy of Child and Adolescent Psychiatry, Practice Parameters, Children and Adolescents with Depressive Disorders, 2007 Texas Medication Algorithm Project, Strategies for the Treatment of Childhood Major Depression, 1999 Columbia University Depressive Disorders Treatment Guidelines Version 2 Lewis’s Child and Adolescent Psychiatry, 2007 David-Ferdon, Kaslow, 2008 Evans, Andrews, 2005 American Foundation for Suicide Prevention, 2008 NIMH, 2008
Childhood Depression
Medication Algorithm
SRI (Fluoxetine)
Alternative SRI
Alternative Antidepressant
Augmentation (Li, BUP, VPA BUS, NEF, VLF, LMG, MIR, AAP)
MAOI
ECT