Depressive disorders in Childhood and Adolescents

Question 1

Prevalence of depression

Answer 1

Pre-pubertal children: 1-2%
Adolescents: 5%
Cumulative prevalence
Girls: 12%
Boys: 7%

The rise in adolescence seems to be more closely linked to pubertal status than to chronological age.

Studies that rely primarily on informants (parents and teachers) report lower rates of depression than studies that rely primarily on the self-reports of children and adolescents.

Before puberty, by contrast, the sex ratio is equal or there may even be a male preponderance.

The female preponderance seen in adult depression is evident from middle or late adolescence.

A link with social disadvantage has been suggested but the evidence is contradictory.

Question 2

List causes of depression

Answer 2

Depression runs in families.
Depressed children are more likely than children with other psychiatric disorders to have parents or siblings who are themselves depressed.
Conversely, parents with depression are more likely to have depressed children.
Twin studies suggest moderate heritability, but this has not been replicated in adoption studies.
There is preliminary evidence that a genetic loading for depression may sometimes act by increasing a young person’s vulnerability to adverse life events ‘a gene–environment interaction’.

Question 3

Name the core symptoms of depression in children

Answer 3

Persistent and pervasive sadness or unhappiness,
Feels unhappy all the time, characterized by a sense of psychic pain e. g., “I can’t stand it”.

Loss of enjoyment of everyday activities (anhedonia),
Has less or no initiative to become involved in any activities and OR be passive – such as watches
others play or watches TV but shows no interest.
Shows no enthusiasm or real interest.

Irritability.
Persistent and pervasive experience of irritability.

Question 4

Name and explain the symptoms of associated symptoms of depression in children

Answer 4

• Negative thinking and low self-esteem
  Refers to himself/herself/themself in negative or derogatory terms e.g., “I’m such a loser”.
  Reports that other children frequently refer to him/her/them using derogatory nicknames.
  Puts himself/herself/themself down.
• Hopelessness
• Unwarranted/ excessive ideas of guilt, remorse or worthlessness
• Morbid ideation (thoughts of death)
  Preoccupation daily with death themes or morbid thoughts that are elaborate,
  extensive.
  If a young child uses word death, explore that they understand what the word means.

Question 5

List other symptoms of depression

Answer 5

• Suicidal ideation (thoughts of suicide)
  Preoccupation daily with suicide themes/ suicide thoughts
  If a child uses the word suicide explore whether they understands the word.
• Lack of energy, increased fatigability, diminished activity,
• Appetite disturbance (decrease or increase)
• Weight changes (decrease or increase)
• Sleep problems (insomnia or hypersomnia)
• Difficulty concentrating, forgetfulness
• Physical / somatic complains- Preoccupied with aches and pains which interfere with play activities.

Question 6

To make a diagnosis of a major depressive episode in practice requires the presence of certain factors. Name these factors

Answer 6

Core symptoms (at least 1 should be present )+ associated symptoms

Minimum of at least 5 symptoms

Pervasiveness (symptoms must be present every day, most of the day)

Duration (for at least two weeks)

Symptoms must cause impairment in interpersonal, social and scholastic functioning or significant subjective or (very young) carer distress, and

Symptoms are not the manifestation of the effects of a substance or another medical condition.
Symptoms should not be due to another mental disorder.

Question 7

Assessing the severity of a major depressive episode - describe mild, moderate and severe episodes

Answer 7

Mild: Five depressive symptoms (at least one core symptom), mild impairment in functioning, mild distress caused by symptoms

Moderate: six or seven depressive symptoms (at least one core symptom), considerable difficulty in continuing with school work, social and family activities

Severe: More than seven depressive symptoms, hallucinations/delusions can be present (psychotic depression), significant risk of suicide often present, severe impairment in most aspects of functioning, significant distress

Question 8

Differences in the presentation of depression according to age (commonest symptoms in each age group)

Answer 8

Prepubertal children: Irritability (temper tantrums), affect is reactive, somatic complaints, frequently comorbid with anxiety, behaviour problems and ADHD.

Adolescents: Irritability (grumpy, hostile, anger), affect is reactive, hypersomnia, increased appetite and weight gain, somatic complaints, extreme sensitivity to rejection resulting, for example, in difficulties maintaining relationships

Adults: Anhedonia, lack of affective reactivity, psychomotor agitation or retardation, diurnal variation of mood (worse in the morning), early morning waking

Question 9

Suicide statistics

Answer 9

Suicidal thoughts:
1/6 girls aged 12 to 16 in last 6 months
1/10 boys aged 12 to 16 in last 6 months
Significantly more attempts than completions
60% depressed youth have thoughts of suicide
30% depressed youth make a suicide attempt

Question 10

Risk factors of suicide

Answer 10

Family history, previous attempts, comorbidities, aggression, impulsivity, access to lethal means, negative life events.

Risk factors for attempted suicide
• There have been suicides in the family
• The young person has attempted suicide previously
• There are other comorbid psychiatric disorders (e.g., substance abuse),
impulsivity, and aggression
• They have access to lethal means (e.g., firearms)
• They have experienced negative events (e.g., disciplinary crises, physical
or sexual abuse), among others.
Suicidal behaviors and risk need to be carefully evaluated in every depressed young

Question 11

Classification of depression

Answer 11

Persistent symptoms of depression that meet the criteria for a depressive episode can be assigned one of several diagnoses,
Depending on
- how many episodes they have had and
whether they have also had any manic,
- hypomanic or mixed episodes.
One major depressive episode with no manic, hypomanic or mixed episodes = major depressive disorder, single.

Two or more major depressive episodes but no manic, hypomanic or mixed episodes = major depressive disorder, recurrent

Those with milder symptoms may meet the diagnostic criteria for persistent depressive disorder (dysthymia) or adjustment disorder with depressed mood.

Dysthymia involves chronic mild symptoms for at least one year (as opposed to the two years stipulated for adults).

An adjustment disorder can be diagnosed if the symptoms occur shortly after an identifiable stressor (within three months according to DSM-5) and do not outlast the stressor by more than six months.

Question 12

Classification of bipolar depression

Answer 12

A bipolar disorder diagnosis should not be made unless there is history of at least one nondrug-induced manic, hypomanic or mixed episode.

Clinical picture can be the same in both, there are characteristics that increase suspicion that a depressive episode may be bipolar, such as a family history of bipolar disorder and the presence of psychotic symptoms or catatonia.

Unipolar-bipolar distinction is made more difficult because bipolar illnesses often start with an episode of depression in childhood or adolescence without previous history of manic symptoms.

Question 13

Discuss comorbidity in depression

Answer 13

Over 50% of depressed children in epidemiological samples have at least one other psychiatric disorder as well

Anxiety disorders
Post Traumatic Stress Disorder
Conduct problems
Attention Deficit Hyperactivity Disorder
Obsessive Compulsive Disorder
Learning difficulties

Rate of comorbidity is often even higher in clinic samples.

Question 14

Differential diagnosis of depression

Answer 14

Normal sadness, including normal bereavement reactions.

Misery can occur as just one feature of another psychiatric disorder, without the additional affective, cognitive and behavioural features needed to diagnose a true depressive disorder.

Mental disorder due other medical conditions e.g., hypothyroidism

Substance or medication induced depressive disorders

Question 15

Depressive disorder due to another medical condition DSM 5

Answer 15

a) A prominent and persistent period of depressed mood or anhedonia (markedly diminished interest or pleasure in all, or almost all, activities) that predominates the clinical picture.
b) There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
c) The disturbance is not better explained by another mental disorder (e.g., adjustment disorder with a depressed mood, in which the identifiable stressor is a serious medical condition).
d) The disturbance does not occur exclusively during the course of a delirium.
e) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 16

What should be included in the psychiatric assessment of

Answer 16

Complete psychiatric hx incl:  
-    Presenting complaint(s); 
-    Systematic review of psychiatric symptoms; 
-    Past psychiatric hx; 
-    Family hx; 
-    Developmental hx; 
-    Medical hx and current treatment. 
Child and parent interview + collateral information from medical, nursing, social work and allied health professionals.

Full mental status examination (MSE)

Physical examination and components of neurological examination where necessary.

Rating scales such as childhood depression inventory (CDI), children’s depression rating scale (CDRS).

Collateral information from school teachers – get parental consent.
Interviews, educational information forms, school reports etc.

Sometimes we do school visits for classroom observation, and home visits.

Aetiological formulation

Risk assessment

Psychiatric diagnosis

Management plan
- Bio-psycho-social model

Question 17

Management of mild and moderate depression

Answer 17

The best plan probably depends on the severity of the depression:
In mild depression, support and stress reduction are often sufficient.
In moderate depression, a three-step plan can be helpful:

Step 1: Try support and stress reduction.
Step 2: If this fails, try CBT or IPT.
Step 3: If this fails, consider a trial of fluoxetine.

Meta-analyses – tricyclic antidepressants are little or no better than placebos for children and adolescents.

Serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, are better than placebos at treating child and adolescent depression (especially, severe depression).

Fluoxetine is the only antidepressant approved by the US Food and Drug Administration (FDA) for the treatment of depression in children.
However, there are also concerns that SSRIs increase the risk of self-harm or suicide.
Analyses of reported adverse effects do suggest an increase in suicidal ideation and threats, with few attempts and no completed suicides.
In the light of reported levels of adverse effects with different SSRIs, the British Government guidelines do not support the use of SSRIs other than fluoxetine for depressed children or adolescents.

Question 18

What are the aims of treatment of depression

Answer 18

Reduce symptoms and impairment
Shorten episode
Prevent recurrences

Question 19

Management of severe depression

Answer 19

In severe depression
Combination – combined pharmacological and psychological treatment.

Admission to an in-patient unit is indicated when there is severe suicidality, psychotic symptoms, or refusal to eat and drink.

Single episode - Continue successful therapy for about six months after symptomatic remission in order to prevent early relapse.

Question 20

Pharmacological treatment of bipolar depression

Answer 20

Pharmacological treatment of bipolar depression poses additional challenges.
Treatment resistance is common
SSRIs can trigger mania
Neuroleptics may be useful, for example, quetiapine alone, or olanzepine combined with fluoxetine.
Mood stabilisers such as lithium or sodium valproate combined with fluoxetine
Lamotrigine.
While resistant depression is best treated in specialist centre

Question 21

Prognosis of depression

Answer 21

Likelihood of recurrence.

• An adjustment disorder with depressed mood usually lasts a few months and does not typically recur.
• Major depressive episodes often last six to nine months and commonly recur.
• Dysthymia typically persists for several years; dysthymic individuals are at a high risk of major depressive episodes.
• Someone with ‘double depression’ (that is, major depressive episodes superimposed on dysthymia) is particularly likely to experience recurrent major depressive episodes.