Depression in Childhood and Adolescence
Depression in Children and Adolescence
General and supportive measures
ICD-10 code: F32 / F33 / F34
DESCRIPTION
The clinical picture of a child and adolescent with major depressive disorder is similar to that of adults except that there are some developmental differences, i.e. 'atypical' symptoms:
- mood is often irritable rather than sad,
- failure to gain weight, rather than weight loss,
- somatic complaints, e.g. headaches and abdominal pain,
- behavioural and academic/school problems occur frequently,
- withdrawal from social activities,
- vegetative symptoms are less common than in adults,
- suicide attempts increase in number and tend to be more lethal, and
- impairment of functioning worsens with increasing age.
The first episode of bipolar disorder can present with depression in adolescents. Bipolar depression is often associated with a more sudden onset, psychomotor retardation, anxiety symptoms, and in some instances, psychotic symptoms and a family history of bipolar disorder.
A number of depressed children and adolescents have co-morbid psychiatric disorders. The most frequent co-morbid diagnoses are:
- Anxiety disorders.
- ADHD
- Oppositional defiant disorder.
- Trauma/Post traumatic stress disorder (PTSD).
- Substance misuse, particularly in adolescents.
DIAGNOSTIC CRITERIA (DSM 5)
The clinical presentation of major depressive disorder includes 5 symptoms present for a period of 2 weeks and represents a change from previous functioning. Changes in either mood or interests must be present:
- depressed mood reported or observed by others,
- decreased pleasure or interest in activities,
- vegetative symptoms including sleep/appetite disturbances,
- fatigue/loss of energy,
- poor concentration/indecision,
- psychomotor agitation/retardation,
- excessive, inappropriate guilty ruminations or feelings of worthlessness, and
- thoughts of death and suicide, suicide attempt or suicide plan.
Symptoms cause distress or impairment in functioning.
Exclude other psychiatric disorders, medical conditions, the effects of substances and manic/hypomanic episodes.
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A suicide attempt is self-inflicted harm where the intention is to die. Increased suicide risk is associated with the following:
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Consider the following in a child presenting with depressed mood:
- Exclude underlying medical conditions such as:
- infections, e.g. HIV, cerebral cysticercosis, encephalitis and tuberculous meningitis,
- neurological conditions, e.g. temporal lobe epilepsy, brain tumours, and
- endocrine disorders, e.g. thyroid conditions, diabetes mellitus.
- Exclude medication-induced mood disturbances, e.g. corticosteroids, antiretrovirals (zidovudine, efavirenz), high doses of stimulant medication and barbiturates.
- Exclude substance abuse, including alcohol and methamphetamine ('tik').
- Assess for suicide risk.
GENERAL AND SUPPORTIVE MEASURES
- Psychological interventions are considered 'first line' for mild to moderate depression and should be administered by a suitably skilled clinician:
- Cognitive behavioural therapy (CBT): to address distorted, negative cognitions, maladaptive patterns of behaviour and communication.
- Psychodynamic/play therapy: to identify feelings, improve self-esteem and social interactions.
- Additional interventions:
- Family counselling: to address family disharmony, stressors and provide psycho-education.
- Input to school: to address academic issues and psycho-education.
- Social worker: to investigate suspicion of child abuse or neglect.
MEDICINE TREATMENT
- If there is a failure to respond to psychotherapeutic interventions after 4 - 6 weeks or if the severity of symptoms increases, consider a trial of antidepressant medication, while continuing with psychotherapy and other interventions. Initiate treatment in consultation with a psychiatrist. Children 12 years and under should be referred to a child psychiatrist for the initiation of medication.
- Response to treatment should bring about a meaningful reduction in symptoms and improvement in functioning.
- Once remission is achieved, continue medication therapy for at least a further 6 - 12 months.
First line:
- Fluoxetine, oral, 0.5 mg/kg/day.
Fluoxetine tablets are registered in South Africa, however, may not be available in the public sector. Fluoxetine may only be available in 20 mg capsules, in which case citalopram tablets can be used initially, titrated to 20 mg and then changed to fluoxetine 20 mg if that dose has been reached.- Dose range: 20 - 40 mg daily
- Recommended average dose: 20 mg/day
If there is a poor response to fluoxetine after an adequate trial of treatment, i.e. 4 - 6 weeks, or if significant symptoms of anxiety are present, or if the child is HIV-infected, consider an alternative SSRI.
Second line:
- Citalopram, oral, 0.4 mg/kg/day
- Dose range: 5 - 40mg daily
- Recommended average dose: 10–20 mg/day
A trial of treatment is considered ineffective if the patient presents with ongoing, significant depressive symptoms and/or suicidal ideation and where the patient has not achieved an improvement in overall level of functioning.
Be aware of the risk of bipolar ‘switch’ or precipitation of mania in patients with a family history of bipolar disorder.
Tricyclic antidepressants are not recommended in children due to insufficient evidence of efficacy, potential adverse cardiovascular side effects and lethality in overdose.
REFERRAL
- Poor response to an adequate trial of treatment, i.e. medication trial of 6 - 8 weeks in combination with psychological treatment and psychosocial interventions.
- Presence of co-morbid conditions.
- Psychotic symptoms such as delusions or hallucinations.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 14: Child & Adolescent Psychiatry, 14.4 Mood Disorders, 14.4.1 Depression In Childhood And Adolescence