Depression

Depression

Depression is a common childhood mental disorder in the United States. For youth ages 12-17 in 2023, 18.1% experienced a major depressive episode and 13.5% experienced a major depressive episode with severe impairment. Major depression is 2-3 times more common in female adolescents compared with male adolescents. Depression extends far beyond typical feelings of sadness and has the potential to disrupt various aspects of a child's daily life. This includes their energy levels, ability to concentrate, sleep patterns, and appetite. Moreover, it can interfere with their functioning at school, within the family and in peer relationships, and may lead to suicidal thoughts. Depression can persist for weeks, months, or even longer, and it's concerning that fewer than half of children with depression receive the necessary treatment. 

Types of Depressive Disorders:

• Major Depressive Disorder  is characterized by feelings of overwhelming sadness or irritability, worthlessness and guilt. Children often lose interest in once-enjoyed activities, frequently expressing boredom. They might also complain of physical symptoms like stomach aches or headaches. Changes in sleep patterns, appetite, and concentration may be observed, and the child may engage in self-harming behaviors or have thoughts related to death and suicide.
• Disruptive Mood Dysregulation Disorder is characterized by prolonged episodes of irritability and atypical tantrums for their age.
• Persistent Depressive Disorder, also known as Dysthymia, is diagnosed when children experience milder but more enduring symptoms of depression.

When Should Providers and/or Caregivers Be Concerned?

It's important to be vigilant when symptoms persist almost daily for several weeks or more, or when they start to significantly affect a child’s daily life. In cases of depression among children and teens, these signs are especially worrisome because they can elevate the risk of serious issues like suicidal thoughts and behaviors, psychosis, and hallucinations. Being aware of these signs is crucial for timely intervention and support.

Screening and Assessment

Assessment Methods

Assessment plays a crucial role in clinically diagnosing depressive disorders, and it starts by gathering information from both the child and their caregivers. The first step is to rule out any other medical conditions that might be behind the symptoms. 
Following that, we dive into a comprehensive assessment. This usually involves a combination of a clinical interview and the use of standardized rating scales. These rating scales are instrumental in helping us figure out whether the child's symptoms are linked to difficulties in their social life, emotions, behavior, academics, or work. They serve as a helpful tool for providers to determine who might require a full assessment. However, it's important to note that rating scales alone are not sufficient to make a definitive diagnosis. 
 

Screening Methods

Healthcare providers have a variety of rating scales at their disposal when evaluating a child for depression. These tools include the Children's Depression Rating Scale, the Hamilton Depression Rating Scale, the Columbia DISC Depression Scale (Teen), and the Beck Depression Inventory (BDI). One of the most commonly utilized rating scales is the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 is not only a valuable resource but accessible, freely available, and quick to complete, taking about five minutes of your time. It can also be useful for monitoring how a child responds to treatment.

The PHQ-9 is scored on a scale of 0-27, with different ranges suggesting varying levels of depression:
 

• 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

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.  

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 dermatologic conditions such as facial acne or eczema; acute injuries that prevent participation in usual activities; and chronic conditions such as diabetes, arthritis, and migraines. 
Severity of depressive symptoms and the level of functional impairment should guide treatment decisions. A PHQ-9 score between 10 and 14 is suggestive of moderate depression. If the clinical assessment matches this, the American Academy of Pediatrics’ Guidelines for Adolescent Depression, or GLAD-PC, recommends counseling with consideration of evidence-based antidepressant treatment. A PHQ-9 score above 15 is suggestive of moderately severe or severe depression. If the clinical assessment matches this, treatment should include counseling with a stronger consideration for medication. 

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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 Features

Major depressive disorder is characterized by a range of alterations in a person's emotions, thoughts, sleep patterns, eating habits, interests, and energy levels, which we often refer to as neurovegetative functions. To make a formal diagnosis, an episode of these symptoms must persist for at least two weeks. In reality, depressive episodes frequently extend beyond this two-week threshold, often involving cycles of improvements and setbacks.  
According to the DSM-5, five or more of the following symptoms need to be present for a diagnosis of major depressive disorder in children and adolescents: 

• Persistent feelings of sadness or irritability for most of the day, nearly every day, lasting at least two weeks. 
• Marked decrease in interest or pleasure in daily activities, nearly every day. 
• Significant changes in appetite and/or noticeable fluctuations in body weight.
• Frequent experiences of insomnia or hypersomnia. 
• Frequent psychomotor agitation or psychomotor retardation. 
• Daily loss of energy. 
• Feelings of worthlessness or guilt. 
• Reduced ability to concentrate or persistent indecisiveness. 
• Frequent thoughts of death, suicidal ideation, past suicide attempts, or a plan to die by suicide. 

Moreover, these symptoms should result in significant distress and cannot be better explained by substance use, another medical condition, another mental disorder, nor can they be followed by periods of elevated mood, such as mania or hypomania. 
It is also important to consider other medical or mental health conditions before the diagnosis of major depressive disorder is established. 

Differential Diagnosis

Given that many symptoms of major depressive disorder can resemble those of other behavioral health and medical disorders, it is crucial to conduct a thorough assessment and remain vigilant about other conditions whose characteristics might overlap. This approach ensures an accurate diagnosis.

• Adjustment Disorder with Depressed Mood –  involves depressive symptoms triggered by a specific stressor but doesn't meet the criteria for Major Depressive Mood Disorder.
• Bereavement – is a natural response to the loss of a loved one, typically less severe than Major Depressive Disorder (MDD).  
• Bipolar Disorder – features one or more manic or hypomanic episodes in addition to depressive symptoms.
• Borderline Personality Disorder – Includes personality features like identity disturbance, self-mutilating behavior, unstable relationships, and chronic suicidality.  
• Depressive Disorder Due to Another Medical Condition – Requires the presence of an underlying medical condition, such as hypothyroidism, contributing to the depressive symptoms.  
• Obsessive-Compulsive Disorder – Involves recurring, anxiety-inducing thoughts, along with compulsions aimed at reducing 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 complex condition that alternates between periods of mood disturbance and periods of delusions/hallucinations, which don't coincide.
• Somatic Symptom Disorder/Illness Anxiety – Focused exclusively on health concerns, preoccupation with becoming ill, or excessive worry about the seriousness of symptoms.
• Substance/Medication Induced – Onset during intoxication, withdrawal or occurring as a side effect of substance use or medication.

Treatment

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

The shared decision-making tools can be used to 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) is an evidence-based treatment for depression which is based on the concept that thoughts, feelings, and behaviors are connected and that changing one will cause changes in the others. Providers can help patients identify distorted thoughts and improve their thoughts, feelings, and behaviors by utilizing various skills.
• Interpersonal Therapy (IPT)  is an evidence-based treatment for depression which is based on the concept that interpersonal relationships and mood have a reciprocal relationship, and that interventions which improve one will improve the other. In IPT, an interpersonal problem area is identified and the therapist and the patient work to help resolve it, and by doing so to improve mood symptoms.  
• Dialectical Behavior Therapy (DBT) targets the improvement of depressive symptoms by honing four key skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. It encourages self-acceptance as a catalyst for positive change.
• Family Therapy is geared towards enhancing family dynamics in a more constructive and positive way. It examines communication patterns and provides support and education. Sessions may include the child, siblings, and caregivers.
• Group Therapy is a form of psychotherapy that involves multiple patients led by one or more therapists. It harnesses the power of education and peer group interactions to enhance our understanding of and recovery from depression.

Resources for Youth and Families

The National Alliance on Mental Illnesses (NAMI) provides psychoeducation for families with adolescents facing depression:

NAMI for kids, teens and young adults

NAMI for family and caregivers

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

Am I Depressed?

Why Depression

For Teachers

In the Classroom

Medication

In the treatment of depression, those with mild cases typically find relief through psychotherapy alone, while moderate to severe depression tends to respond best to a combination of psychotherapy and medication management.
Antidepressants are the primary pharmacological approach for pediatric depressive disorders. Selective serotonin reuptake inhibitors (SSRIs) stand out as the preferred first-line treatment, thanks to their notable safety, tolerability, and effectiveness profile, supported by strong evidence. Currently, the Federal Drug Administration (FDA) has approved two drugs, Fluoxetine and Escitalopram, for the treatment of Major Depressive Disorder in youth. Among these, Fluoxetine is the sole medication approved for children under the age of 12 who are dealing with Major Depressive Disorder. 

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

For additional resources, visit the Ohio Medicaid Pharmacy Program.

Monitoring Treatment

Active monitoring of a treatment plan includes recommended follow-up every four weeks until stable, regular follow-up at least every three months with patient via telehealth and/or in-person, and monitoring the effects of therapy.

SSRI Box Meeting

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. A more detailed discussion of suicide risk can be found in the Suicide and Suicide Risk module. 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, 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:

Approximate Dosing Equivalents

Typical Maximum Doses of SSRI's

For more information see Antidepressant Medication Aid

Side Effects

• Common side effects include
  • Nausea, diarrhea- typically transient, resolving within a week.
  • Sleep disruption, insomnia, or increased sleepiness without or without intense dreams. 
  • Headache, body aches, or fatigue
• When in doubt, decrease dose and consult with a psychiatrist.

Managing Side Effects

“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:  A 16-year-old patient started on escitalopram 5 milligrams and increased to 20 milligrams over eight weeks. Patient 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, which involves 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 aims to reduce 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 milligrams and increase sertraline to 50 milligrams, check in with clinician
• week 3: stop fluoxetine and increase sertraline to 100 mg

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, have family monitor for reemergence of depressive symptoms, and follow up in 2 months

Clinical Pearl: Antidepressants for Adolescents

The pace of titration for medication can vary depending on the level of functional impairment the patient is demonstrating and the primary concern of the patient and family. 

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Do they seem primarily concerned about adverse effects from medication? Or about not intervening quickly enough to help relieve symptoms?

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In general, outpatients need a minimum of 1 week between dose changes of an antidepressant to gather a few data points about adverse effects. Multiple data points are important so that we are less likely to incorrectly attribute a fleeting change to the medicine. To begin to get clues about how a medicine is starting to help, go 2 weeks between dose changes. If the patient and family are very concerned about tolerability or are especially focused on using the lowest effective dose, go slower than that, although this can extend the time needed to reach significant benefit from the medicine. 

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 with a method or a plan, prior suicide attempts identified, significantly impaired functioning, or serious trauma.

Family Support

Caregivers and family members play a crucial role in supporting youth dealing with depression. They can provide this support by offering social and emotional assistance, acting as positive role models, and helping the young individuals adhere to their medication and treatment plans. In some cases, implementing more structure within the home environment, such as setting reasonable boundaries on the use of social media and gaming, can be beneficial. Other ways families can help include:

• Attend regularly scheduled visits with primary care provider. 
• Promote healthy eating, physical activity, and sleep hygiene.
• Develop resilience-building skills.
• Educational resources
  • Depression Mood Disorder
  • Kids Health
  • NAMI

Resources

AAP Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Identification, Assessment, and Initial Management

AAP Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Treatment and Ongoing Management

GLAD-PC Toolkit for Screening, Diagnosing, Treating, and Monitoring Adolescent Depression in the Primary Care Setting AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders Florida Best Practice Medication Guidelines 07: Depression Under 6 Years - Treatment Flowchart

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. (2024). Family Members and Caregivers. https://www.nami.org/your-journey/family-members-and-caregivers/

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