12: Depression

Question 1

Why are underdiagnosis and undertreatment problems with younger children?

Answer 1

Often present atypically (stomach aches) and will be seen by school nurse.

Question 2

T/F Depression can be genetic.

Answer 2

True. Children with depressed parents have 3x the risk to be diagnosed, with peak incidence between 15-20. However, 1/3-1/2 of children develop depression in the absence of family hx.

Question 3

What depression diagnosis was removed from DSM-5?

Answer 3

Depression related to adjustment situations and bereavement. Remaining ones are: major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, and depressive disorder d/t another medical condition.

Question 4

What is the only FDA approved medication for depression in children?

Answer 4

Prozac

Question 5

What are the duration guidelines for med treatment for depression in children (3)?

Answer 5

1. If no benefit after 4 weeks, consider another medication.
2. If mild response, consider continuing for 10 weeks to optimize response.
3. Duration of treatment up to 1 year (sometimes lifelong).
4. Symptom-free for 3 months before decreasing dose
5. Monitor closely - 40-50% relapse within 2 years

Question 6

If history is used to diagnose depression, why must a PE be performed?

Answer 6

To differentiate among organic causes (anemia, chronic fatigue, eating disorder, etc.).

Question 7

What is the typical length of time to treat depression pharmacologically in children?

Answer 7

Typically 6-9 months, but can be up to 1 year. Until child demonstrates normal mood level. Taper slowly.

Question 8

How do school-age children present with depression (7)?

Answer 8

Able to verbalize, but don’t always:

1. Irritability/anger
2. Hyperactivity
3. Difficulty handling feelings
4. Frequent absences, school phobia
5. Loss of interest
6. Describing themselves in negative terms
7. Feeling guilty about behaviors

Question 9

Of children 9-17 years old, _____% have a diagnosable mental or addictive disorder.

Answer 9

21%

Question 10

What are the DSM-5 criteria for diagnosis of dysthymia (persistent depressive disorder)?

Answer 10

An overwhelming, chronic state of depression that is present on most days for at least 2 years. Baseline mood is irritable or depressed. Must not have gone for more than 2 months without 2 of:

1. Poor appetite/overeating
2. Insomnia/hypersomnia
3. Low energy
4. Low self-esteem
5. Difficulty making decisions
6. Feelings of hopelessness

Question 11

T/F Children and adolescents with mood disorders often present first with somatic complaints such as headaches.

Answer 11

True

Question 12

6 manifestations of major depression in adolescents.

Answer 12

1. Severe sadness
2. Withdrawn behavior
3. Boredom
4. Low self-esteem
5. Feeling helpless and hopeless
6. Sense that there is no meaning in life

Question 13

What is first-line pharm therapy for depression in children?

Answer 13

SSRIs. Most trials have not demonstrated great effectiveness. Reserve for major depression. Tricyclics are second line. They are rarely used d/t side effects.

Question 14

Half of all lifetime mental disorders begin by age _____.

Answer 14

14

Question 15

T/F Childhood depression is often only recognized after noticing difficulty in school and social functioning.

Answer 15

True

Question 16

What is the management of depression (3)?

Answer 16

1. Assess for suicide risk/plan
2. Meds
3. Counseling (refer…we are not counselors!)

Question 17

How do toddlers present with depression (9)?

Answer 17

1. Lack of energy
2. Eagerness to please/clingy
3. Separation problems
4. Sadness
5. Poor appetite/weight loss
6. Sleep issues
7. Regression
8. Increased physical complaints
9. Overall behavior problems

Question 18

What are the DSM-5 criteria for diagnosis of major depressive disorder?

Answer 18

5 or more symptoms must be present in the same 2-week period and at least 1 symptom must be depressed mood or loss of interest/pleasure. Others:

1. Weight change/appetite change
2. Insomnia or hypersomnia
3. Psychomotor agitation
4. Fatigue/loss of energy
5. Disturbed concentration or indecisiveness
6. Recurrent thoughts of death, suicide, or suicide attempt

Question 19

How do adolescents present with depression (6)?

Answer 19

1. Decreased interest
2. Withdrawal
3. Hopelessness
4. Changes in weight/appetite
5. Changes in sleep patterns
6. Substance abuse

Question 20

What is the black box warning for SSRIs and some antidepressants?

Answer 20

Can increase suicidal ideations and attempts in those under 26.

Question 21

T/F It is difficult to distinguish between depression and “normal” adolescent growth and development and it is the leading cause of suicidal behavior and suicide.

Answer 21

True. It is difficult to differentiate b/c adolescents have developmental transitions, temperamental manifestations, and irritable moods.

Question 22

What acronym should be used at every child assessment to cover the important topics during history taking?

Answer 22

HEADSS
Home
Education/employment
Activities
Drugs
Sexuality
Suicide

Question 23

Depression is twice as common in _____ by age 14.

Answer 23

Girls

Question 24

What is the one classic study that looked at treatment of depression in adolescents?

Answer 24

Treatment for Adolescents with Depression (TADS) 2004

Question 25

T/F Adolescents and their cognitive development allow for more mature feelings of despair, blame, guilt, self-hate. They are capable of abstract thinking and recognizing feelings.

Answer 25

True (Piaget)

Question 26

Depression should be treated for a minimum of _____ months.

Answer 26

6 months

Question 27

T/F Depression is not present in those less than age 5.

Answer 27

False. Does occur, but true incidence is not known d/t lack of ability to properly communicate feelings.

Question 28

How do infants and young children present with depression (6)?

Answer 28

Unable to verbalize:

1. Depressed affect
2. FTT
3. Developmental delays
4. Repetitive self-soothing behaviors (rocking)
5. Poor attachment behaviors
6. Loss of developmental skills

Question 29

According to the TADS study, what is the best treatment for adolescents with depression?

Answer 29

Medication + cognitive behavioral therapy (CBT). Though it did show that medication alone or in combination with CBT was better than CBT alone.

Question 30

What are the depression screening tools available (4)?

Answer 30

1. Child behavior checklist (4-18 yo)
2. Children’s depression rating scale (6-12 yo)
3. Beck depression inventory (adolescents and adults)
4. PHQ-9 (PHQ-2)

Question 31

What is first line treatment for mild-moderate depression in children?

Answer 31

CBT (psychotherapy)

Question 32

What is the most important part of the visit in diagnosing depression in children and adolescents?

Answer 32

History Assessment. Diagnosis is often missed b/c symptoms are not recognized by parents, family, providers, or school. Need history from family and school, as children may not accurately report moods.