Depression

Depression

Depression is a common childhood mental disorder that affects up to 3% of children, and up to 13% of adolescents. Additionally, up to 20% of adolescents who experience depression are female. Depression is more severe than typical sadness and can interfere with several aspects of a child’s daily life, including energy levels, ability to concentrate, sleep patterns and appetite. Furthermore, depression can affect a child’s ability to function normally at school, within a family and within peer relationships. Depression can last for weeks, months or even longer. Fewer than half of children with depression receive the treatment they need. Early detection and treatment by a healthcare professional is vital to successfully manage the symptoms associated with depression.

 

Types of Depressive Disorders:

  • Major Depressive Disorder is characterized by feelings of overwhelming sadness or irritability, worthlessness and guilt. Children often lose interest in activities that once gave them pleasure and are frequently bored. They may also complain of physical symptoms, such as stomach aches or headaches. The child’s sleep patterns, appetite, and/or concentration might change. Additionally, the child may engage in self-harm or have thoughts of death and/or suicide.
  • Disruptive Mood Dysregulation Disorder is characterized by symptoms of irritability that occur for long stretches of time, as well as frequent tantrums that are atypical for age-range. 
  • Persistent Depressive Disorder (Dysthymia) is indicated when children experience milder, but much longer lasting symptoms of depression. 
  • Depression and Mixed Features is characterized by symptoms of depression along with manic or hypomanic symptoms.

 

When Should Providers and/or Caregivers Be Concerned?

Concern is warranted when symptoms are seen nearly every day for several weeks or longer, or when symptoms have a significant impact on the child’s life. Children and teens who are depressed are at greater risk of suicide, psychosis, and hallucinations.

Myths vs. Facts About Depression

Fact: Children do not have the same verbal skills as adults and may not be able to articulate their feelings. Symptoms in children may present as aches and pains, fatigue, tearfulness, guilt, isolation and irritability.

Fact: Since children may hide these feelings, a professional can help to determine their diagnosis.

Fact: Oftentimes intervention is needed to improve symptoms.

Fact: It is recommended to encourage children to talk about their feelings and emotions.

Fact: In Ohio, suicide is the second leading cause of death ages 10-24.

Fact: Treatments are available to help treat depression in children.

Fact: Depression can be treated, and children can go on to live normal and happy lives.

Fact: Unrecognized or untreated depression is directly linked to an increased use of illegal drugs and/or alcohol.

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Meet Morgan

Morgan is a 10-year-old female with an unremarkable medical and psychiatric history who presents to her primary care practitioner (PCP) with persistent stomach aches, fatigue, and lack of appetite. Her parents are concerned that she seems withdrawn and has not been participating in activities that she usually enjoys, such as hanging out with her friends and playing sports. Morgan’s teachers have also commented on her seeming tired in class and her falling behind on her class assignments.

Medication

None

Psychosocial

Morgan lives with her mother, father, and maternal grandparents. There is no history of trauma or CPS involvement.

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Meet Daniel

Daniel is a 15-year-old male with no active medical problems and no previous history of contact with mental health providers. He usually keeps his feelings to himself, but when his mom brought up her concerns to him, he admitted to feeling worthless lately. His mom called the primary care provider’s office to discuss this, and an appointment was scheduled.

Medication

None

Psychosocial

Daniel lives with his mother, stepfather, and 7-year-old brother. Mom has a history of depression which is currently well-controlled with pharmacotherapy.

Screening and Clinical Evaluation

Depressive disorders in children and adolescents require a clinical diagnosis, which is typically initiated by collecting information from the child and caregivers. Assessment begins by ruling out other medical conditions that may be causing the symptoms. Next, a comprehensive assessment is completed, which may include a combination of a clinical interview and the use of standardized rating scales. Standardized rating scales are neither definitively diagnostic, nor a definitive indication of a specific condition. The intent of the rating scales is to determine if the symptoms experienced by the child are contributing to their social, emotional, behavioral, academic, or work challenges.  
 
There are several rating scales available to assist healthcare providers when evaluating a child for depression. Examples include the Children’s Depression Rating Scale, Hamilton Depression Rating Scale, Columbia DISC Depression Scale (Teen), and the Beck Depression Inventory (BDI). One of the most used rating scales is the Patient Health Questionnaire-9 (PHQ-9). The scale is free, takes about five minutes to complete, and may also be useful in tracking treatment responses. Below is a representation of how the PHQ-9 is scored and evaluated:

  • 0-4: No depression
  • 5-9: Mild depression
  • 10-14: Moderate depression
  • 15-19: Moderately severe depression
  • 20-27: Severe depression

PHQ-9 For Depression

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Morgan

Morgan and her parents attend their scheduled appointment with their pediatric primary care provider (PCP). Morgan has difficulty answering open-ended questions about her mood, but she and her parents describe her gradually increasing disengagement from friends and activities. She also answers questions about changes in sleep, appetite, and concentration. Morgan denies having any thoughts of suicide. The PCP completes a family history and identifies that Morgan’s biological father has a history of depression that has been treated successfully with Zoloft. The PCP also completes a physical assessment with no abnormal findings.

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Daniel

Daniel’s mother accompanies him to his appointment and reports an approximately 3-month history of increasing irritability (“we are all walking on eggshells around him”), increasing tendency to isolate in his room and play video games, disrupted sleep-wake cycles, worsening school performance, and decreased interest in extracurricular activities. Daniel completes a PHQ-9 Modified for Adolescents, with a score of 13, indicating that he is moderately depressed. On item nine of the PHQ-9 Modified for Adolescents, which asks about “Thoughts that you would be better off dead, or of hurting yourself in some way,” he marks “Several days.” However, on the item which asks “Has there been a time in the past month when you have had serious thoughts about ending your life?” he answers “No.” When meeting with Daniel alone, the PCP asks him about these responses and he reports that he has had some days where he felt it would be good if he were not around, but he does not intend to act on this thought and has not made any plan to end his life.

Clinical Pearl: Depression Treatment Planning

Identification and interventions for general medical conditions that may be negatively impacting mood will help with treatment and planning. Common conditions that can negatively impact mood include facial acne, acute injuries, and pain.


Severity of depressive symptoms and level of functional impairment should guide treatment decisions.


Asking youth about thoughts of suicide does not increase the likelihood of suicidal thoughts and is a cornerstone of assessing symptoms of depression at baseline, course of illness over time, response to treatment, and possible adverse effects of pharmacotherapy.

 

Diagnostic Criteria

It is also important to consider other medical or mental health conditions before the diagnosis of depression is established. See “Differential Diagnosis” for details.  

Diagnostic Features

Depression is characterized by changes in affect, cognition, and neurovegetative functions. An episode of two weeks is required for diagnosis. However, depressive episodes tend to last longer than this two week requirement, and there are often cycles of remissions and relapses. According to the DSM-5, five or more symptoms must be present to be diagnosed with depression. In children and adolescents, these symptoms include: (1) depressed or irritable mood for most of the day, nearly every day for at least two weeks, (2) decreased interest or pleasure in daily activities, nearly every day, (3) a significant decrease or increase in appetite and/or significant changes to body weight, (4) frequent insomnia or hypersomnia, (5) frequent psychomotor agitation or psychomotor retardation, (6) loss of energy nearly every day, (7) feelings of worthlessness or guilt, (8) decreased ability to concentrate, or indecisiveness, and/or (9) frequent thoughts of death, suicidal ideation, previous suicide attempts, or a plan for committing a suicide attempt. Furthermore, the symptoms cause clinically significant distress and cannot be better explained by substance use, another medical condition, another mental disorder, nor are depressive episodes followed by periods of mania or hypomania.

 

Differential Diagnosis

Since many symptoms of depression resemble those of other behavioral health disorders, it is important to thoroughly assess to ensure an accurate diagnosis. Some of the common differential diagnoses and distinguishing symptoms of depression are listed below:

  • Adjustment Disorder with Depressed Mood – Depressive symptoms that occur in response to a stressor, and do not meet criteria for Major Depressive Mood Disorder.
  • Bereavement – Response to the loss of a loved one, and generally less severe than MDD.
  • Bipolar Disorder – Includes one or more manic or hypomanic episodes. 
  • Borderline Personality Disorder – Additional personality features such as identity disturbance or self-mutilating behavior.
  • Depressive Disorder Due to Another Medical Condition – Requires presence of a medical condition (for example, hypothyroidism). 
  • Obsessive-Compulsive Disorder – Repetitive, anxiety provoking thoughts that are experienced as intrusive, unwanted, or inappropriate, along with a compulsion to reduce anxiety.  
  • Post-Traumatic Stress Disorder or Acute Stress Disorder – Anxiety occurring in response to internal or external triggers that resemble an aspect of a traumatic event, hyperarousal, reactivity to an event, frequent nightmares or flashbacks.
  • Schizoaffective Disorder – A condition with periods of mood disturbance and periods of delusion/hallucinations that do not coincide, but rather alternate.
  • Somatic Symptom Disorder/Illness Anxiety – Focused exclusively on health, becoming ill, or seriousness of symptoms.
  • Substance/Medication Induced – Onset during intoxication, withdrawal or occurring as a side effect.

Treatment

A multi-modal approach involves management strategies that include both non-medication interventions and medication interventions.

Shared decision-making can encourage children, teens, and caregivers to have a voice in their care. The Ohio Minds Matter Shared Decision-Making Toolkit is a guide for youth and families to take an active role in their treatment, prepare for their appointment, consider treatment options, document their symptoms, and describe their goals.

 

Shared Decision Making

 

 

Non-Medication Interventions

Psychotherapeutic Treatment is the recommended first choice in treatment. Also called “Talk Therapy,” the goal is to help the patient identify and change emotions, thoughts, and behavior.

  • Individual Therapy – Cognitive Behavioral Therapy (CBT) helps improve a child's mood by modifying thoughts that cause feelings and moods.
  • Interpersonal Therapy (IPT) helps improve mood by improving interpersonal relationships.  
  • Dialectical Behavior Therapy (DBT) helps to improve symptoms of depression by focusing on four skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. DBT encourages ‘self-acceptance’ to encourage positive change.
  • Family Therapy focuses on helping the family function in a more positive and constructive ways by looking at patterns of communication and providing support and education. Family therapy sessions can include the child or adolescent along with parents, siblings, and grandparents. 
  • Group Therapy is a form of psychotherapy where there are multiple patients led by one or more therapists. It uses the power of education and peer group interactions to improve our understanding of and recovery from depression.

 

Resources for Youth and Families

The following guide created by the National Alliance on Mental Illnesses (NAMI) provides psychoeducation for families with adolescents facing depression:

NAMI Family Guide on Adolescent Depression

 

Kids Health provides psychoeducation for parents, children, and teens separately, catering to everyone impacted by child or adolescent depression:

Kids Health

For Parents

Teen Depression

For Teens

Depression Tips

Depression

Severe Depression

Why Depression

For Teachers

In the Classroom

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Morgan

The diagnostic impression is that of mild Major Depressive Disorder (MDD). The PCP educates Morgan and her family about potential causes, risks, and management strategies for MDD. Morgan’s plan of care includes CBT and Family Therapy with a licensed child and family counselor and follow-up with her PCP. For initial steps in management, given the impression of her depression as “mild” and the plans to refer for psychotherapy, no pharmacotherapy is used.

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Daniel

The diagnostic impression is moderate Major Depressive Disorder (MDD). The PCP asks Daniel questions to clarify suicide risk and describes the potential benefits of psychotherapy and pharmacotherapy. Daniel and his mother accept a referral for psychotherapy and discuss starting fluoxetine, which has been helpful for his mom, at a dose of 10mg daily. The PCP discusses adverse effects to watch for when starting pharmacotherapy, including an increase in suicidal thoughts or behaviors.

Medication

Mild cases of depression should be treated with psychotherapy, however, moderate to severe depression responds best to combination treatment with psychotherapy plus medication management.

Antidepressants are considered the first line of pharmacological treatment for pediatric depressive disorders. SSRIs have a superior safety, tolerability and effectiveness profile and a stronger knowledge base than is currently available for newer antidepressants. Fluoxetine and Escitalopram are currently the only drugs approved by the FDA for treating MDD among youth, and fluoxetine is the only medication approved by the FDA for treating MDD in children under the age of 12.

For SSRI and SSNRI prescribing guides see the Antidepressant Medication Aid

See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.

Medicaid Unified Preferred Drugs List

 

SSRI Box Warning

SSRIs carry a Box Warning due to a rare but significant risk of increased suicidality in the initial stages of treatment. It is important to talk about the boxed warning with families during medication management visits and direct them to notify a provider if suicidal thoughts or behaviors develop or intensify. Most studies suggest that the potential benefits of adding SSRI treatment for moderate to severe anxiety or depression treatment far outweigh the minimal potential risk that patients will experience increased suicidal ideation.

  • In discussing the boxed warning with patients and families, it can be helpful to link the discussion to the need to notify a provider if suicidal thoughts or behaviors develop or intensify, regardless of the reason. For instance: “I mention this not because I think the medication will cause you to be suicidal – that does not seem at all likely to happen – but because if you were having suicidal thoughts (or more frequent or intense suicidal thoughts), it would be important for you to talk with an adult you trust, like me, your therapist, or your caregiver about them.
  • There is evidence of reduced suicide risk when adolescents receiving antidepressant medication also receive psychotherapy.
Prescribing Principles

When starting an SSRI medication in a patient who has never taken this type of medication, it is important to start at a low dose for the patient’s age and weight.  

This allows clinicians to assess the patient’s tolerability of the medication. After two weeks, the medication should be increased in regular intervals (2 to 4 weeks) until the patient’s symptoms are significantly improved or they cannot tolerate a dose high enough to achieve symptom relief or the maximum dose of the medication is reached.

Typical Starting Doses of SSRI’s:
Medication Pre-pubertal Children Peri-pubertal Children Post-pubertal adolescents
Fluoxetine 2.5- 5 mg 5- 10 mg 10 mg
Escitalopram 1- 2.5 mg 2.5 mg 5-10 mg
Sertraline 12.5 mg 12- 25 mg 25- 50 mg

For more information see Antidepressant Medication Aid

 
“Failure” of an SSRI Medication

To say that a patient has failed a trial of an SSRI, they must have reached a maximum tolerated dose for four weeks and have been on medication for a total time of over eight weeks without receiving meaningful benefit.

Example: 12 y/o patient started on fluoxetine 5 mg and titrated up to 20 mg without side effects or symptomatic relief over 12 weeks. This is not a treatment failure as they did not reach a maximum dose, either by tolerability or dosing threshold. This patient should have the fluoxetine increased. 

Example: 16 y/o patient started on escitalopram 10 mg and increased to 20 mg over eight weeks. Patients had significant somnolence and GI symptoms at the higher dose and did not achieve symptom relief. Escitalopram should be discontinued due to treatment failure.

 

Cross Tapering

When a patient has failed their first SSRI, the next step is to switch to another SSRI. This can be done by cross tapering or starting a second medication and increasing its dose at the same time the first medication is being weaned down. One can think of this as going up on the dose of a new medication in a stepwise manner while going down on the dose of the ineffective medication in the same stepwise manner. This approach reduces potential side effects that can emerge at the time of SSRI discontinuation and allows clinicians to achieve dose equivalence of the newly started SSRI quickly. 
There are no agreed upon time intervals for dose adjustments during a cross taper. In general, dose changes can take place after a few days or a week. The longer a patient has been on a medication, the longer it should take to wean. 

Example of a Cross Tapering Schedule: patient currently on fluoxetine 40 mg and switching to sertraline

  • week 1: decrease fluoxetine to 20 mg and start sertraline 25 mg 
  • week 2: decrease fluoxetine to 10 mg and increase sertraline to 50 mg, check in with clinician
  • week 3: stop fluoxetine and increase sertraline to 100 mg
Approximate Dosing Equivalents
SSRI Step 1 Step 2 Step 3 Step 4
Fluoxetine 10 mg 20 mg 40 mg 60 mg
Sertraline 25- 50 mg 50- 100 mg 100- 150 mg 200 mg
Escitalopram 5 mg 10 mg 20 mg 30 mg
Side Effects
  • Common side effects include
    • Nausea, diarrhea- resolve in several days, typically transient. 
    • Sleep disruption without or without intense dreams. 
    • Increased blood pressure for SNRIs. 
  • Black Box Warning: There is a rare but significant risk of increased suicidality in the early stages of starting antidepressants. See the Clinical Pearl: Black Box Warning below.
  • When in doubt, decrease dose and consult with a psychiatrist.
Managing Side Effects
Patient Reports Clinical Description Action to Consider
Uneasy restless feeling, need to move legs/walk around, diaphoresis Akathisia Lower dose, titrate slowly
Restlessness, increased impulsivity, difficulty falling asleep Activation Lower dose, titrate slowly
Dizziness, nausea/emesis, h/a, gait instability, myalgias, fatigue Withdrawal syndrome Restart or reinstate low to moderate dose
Clonus, disorientation, increased blood pressure, fever Serotonergic toxicity Reduce drug interactions, seek consultation in severe cases
Bizarre behaviors, not sleeping for days, rapid speech, extreme irritability Mania (rare) Stop medication and consult with psychiatrist
SSRI Discontinuation

The goal of treatment with SSRIs is to achieve symptom remission. Once a patient has significant improvement in their symptoms, an SSRI should be continued for 12 months before it is weaned off. In this instance, the SSRI should be weaned slowly to allow for adequate monitoring of potential symptom recurrence. 

Example of discontinuation schedule: 15 y/o patient has been on fluoxetine 40 mg for 12 months with symptom remission.

  • Month 1: fluoxetine 30 mg daily and follow up visit to monitor symptoms 
  • Month 2: fluoxetine 20 mg daily and follow up visit to monitor symptoms
  • Month 3: fluoxetine 10 mg daily and follow up visit to monitor symptoms
  • Month 4: stop fluoxetine

Clinical Pearl: Antidepressants for Adolescents

For the two antidepressants approved by the FDA for MDD in youth, fluoxetine, and escitalopram, only fluoxetine has been shown to be beneficial for pre-adolescents. In adolescents, family history of positive response or adverse effects may help guide which of the two agents to choose. 


Although not FDA-approved, sertraline is also a reasonable consideration to treat MDD in youth, particularly in adolescents. It is appropriate to consider it in cases where family history of positive response or adverse effects, such as those seen in a first-degree relative, suggests that sertraline may have a better outcome. 


Venlafaxine, a selective serotonin and norepinephrine and reuptake inhibitor, is considered a poor choice for initial management of depression in most youth, due to evidence that the increase in suicidal thoughts and behavior when starting an antidepressant is a larger concern for venlafaxine than the FDA-approved agents.  Some evidence from early studies of paroxetine indicates an elevated risk of suicidal thoughts and behaviors in youth from this medicine as well.

Ongoing Management

Depression can be managed in primary care as a chronic condition with follow-up of symptoms, treatment engagement, side effects and psychoeducation.

  • Monitor medication compliance and side effects.
  • Continue to monitor for 6 – 12 months. 
  • Titrate medicine within the therapeutic dose range.
  • Provide anticipatory guidance including interventions to build resilience
  • Seek consultation or refer to a specialist if any of the following occur: suicidal Ideation, prior suicide attempts identified, significantly impaired functioning, or serious trauma.
Family Support

Caregivers and family members may assist youth by providing social support, modeling positive behaviors, and assisting with adherence to medication and treatment plans. Some youth may benefit from increased structure in the home environment, including limitations on use of social media and  gaming.

Frequently Asked Questions

Depression has no single cause. Both genetics and the environment play a role.

Medication can be a safe and appropriate intervention for children and adolescents with depression. However, medication is most effective when used as a component of a comprehensive treatment plan, individualized to the needs of the child and family.

Suicide is a serious and growing problem among children and adolescents. Each year, thousands of young people commit suicide. Suicide is the second leading cause of death for 10-to-24-year-olds, and the sixth leading cause of death for 5-to-14-year-olds.

References

  1. Anxiety Disorders Association of America (n.d.). Anxiety Disorders in Children. https://adaa.org/sites/default/files/Anxiety%20Disorders%20in%20Children.pdf
  2. Dulcan, M. (2015). Dulcan's textbook of child and adolescent psychiatry (2nd ed.). American Psychiatric Association Publishing
  3. Dulcan, M. (2022). Dulcan's textbook of child and adolescent psychiatry (3rd ed.). American Psychiatric Association Publishing
  4. Feder, J., Tien, E., & Puzantian, T. (2018). Child medication fact book for psychiatric practice. Carlat Publishing, LLC
  5. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A., Edwards, V., Poss, M.P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4) 774–786. https://doi.org/10.1016/s0749-3797(98)00017-8
  6. First, M. B. (2014). Dsm-5-Tm Handbook of differential diagnosis. American Psychiatric Publishing
  7. Kids Health. (n.d.). Kids Health. https://kidshealth.org/#catemotion
  8. National Alliance on Mental Illness. (2010). What families need to know about adolescent depression. https://www.nami.org/getattachment/Press-Media/Press-Releases/2010/NAMI-Releases- Family-Guide-on-Adolescent-Depressio/FamilyGuide2010.pdf
  9. National Alliance on Mental Illness. (2020). 7 Myths about pediatric depression. https://nami.org/Blogs/NAMI-Blog/August-2020/7-Myths-About-Pediatric-Depression