| Abstract|| |
Pediatric depression is difficult to identify and manage because of complex nature of the disorder. Psychological and cognitive developments impact the clinical presentation and often make assessment tenuous. In addition, the disorder is often associated with multiple biological, psychological, and environmental risk factors, which need thorough assessment. Clinical presentation varies from subsyndromal depression to depression with psychotic features. Although diagnostic criteria for depression remain the same for children; deciphering symptoms need specialized clinical training. This article discusses identification and assessment of depression in the pediatric population. Specialized interviewing techniques pertaining to assessment in this unique population are discussed. Evidence-based guidelines for management of pediatric depression in terms of both pharmacotherapy and psychotherapy are also enumerated. Choice of medication based on multiple parameters with available evidence base is discussed. Treatment planning and continued evaluation on long-term basis are also elaborated.
Keywords: Childhood, depression, diagnosis, management, practice parameter
|How to cite this article:|
Patra S. Assessment and management of pediatric depression. Indian J Psychiatry 2019;61:300-6
| Introduction|| |
Symptom presentation of depression in children varies with age. Often, it is difficult to identify depression in this age group. Emotional and cognitive developments influence the symptom presentation, so do comorbidities. Prevalence of depression is about 2% in prepubertal children, which increases to 4%–8% in adolescents. Recent epidemiological studies show an increasing trend of depression in youth. Childhood depression is a recurrent, relapsing condition causing significant morbidity and mortality. Onset of depression in childhood often results in poor academic outcome, long-standing impairment, poor quality of life, and high risk for suicide and substance abuse. Here, I discuss the clinical presentations of childhood depression with focus on assessment and management based on evidence-based guidelines.
| Case Vignettes|| |
Tarun*, a 4-year-old boy, underwent hospitalization for intractable vomiting. He was sent for psychiatric care when no physical basis of symptoms could be identified. His vomiting would become worse when he approached school so much, so that his parents stopped sending him to school. He appeared dull, listless, became jittery when offered the chair. He did not look at the crayons or balloons which were his favorite.
Taslima*, an 11-year-old girl, had deteriorated in her studies to the extent of scoring 24 out of 100 in her session examinations. Earlier an Avid Reader, she would not even feel like looking at her books and would often get reprimanded for keeping her belongings in a disorderly manner. She would not take the phone from her mother even when offered to talk to her aunt, which she used to earlier fight for.
Although the diagnostic criteria for diagnosing depression remain the same even for children and adolescents, application of these is often felt difficult as symptoms differ by age due to cognitive, emotional, and social aspects of development. Biological functions such as sleep and appetite may not be disturbed, but experience of low mood, anhedonia, and cognitive distortions is distinctly felt.
| Clinical Presentation|| |
Childhood depression is currently conceptualized to be similar to depression in adults. Clinical presentation varies as per the level of development, comorbidities, course, and outcome are also different from depression in adulthood. While children may not verbalize feeling depressed, there may be irritability, temper tantrums, mood lability and low frustration tolerance, somatic symptoms, and withdrawn behavior.
| Symptoms|| |
Symptoms of depression vary as per age and developmental level; affective symptoms and cognitive distortions in childhood are similar to adults, whereas biological symptoms such as changes in sleep and appetite are different. Hypersomnia, decreased appetite, and weight loss are more common in adolescents as compared to children. Delusions are also uncommon in children. Negative cognitions such as low self-esteem, hopelessness, and negative attributions are common in children.
| Comorbidities|| |
Comorbid psychiatric disorders are seen in 80%–95% of children and adolescents with depression. This Axis I disorder comprises anxiety disorders, conduct disorders, and attention deficit hyperactivity disorder. The most common comorbidity being separation anxiety disorder in children.
| Assessment of Depression|| |
Both parent and child interviews are needed for diagnosis of depression. Open-ended questions are used for initial assessment of depression as well as comorbid conditions such as anxiety, attention-deficit/hyperactivity disorder, and conduct disorder. Furthermore, contextual factors such as family environment, school problems, and interpersonal difficulties need to be assessed to ascertain their role as precipitating and perpetuating factors for depression. Assessment of risk for suicide is also essential to monitor the ongoing suicide risk if any.
More structured assessment is then taken up to assess symptoms and severity of depression.
All these initial assessments are continued on an ongoing basis to monitor clinical progress.
In addition to clinical interviews, other methods like pictorial instruments can be used, which can be useful for better clinical understanding of mental state of children because of their age appropriateness in communicating abstract thoughts and emotions.
Pictorial instrument for children and adolescents
Pictorial Instrument for Children and Adolescents (PICA-R) is a semi-structured pictorial instrument for 6–16-year-old children. Pictorial instrument which uses concrete means of visual communication provides a way of reducing the impact of cognitive difficulties, attentional problems, and language limitations inherent in verbal interviews. PICA-R generates a categorical diagnosis with dimensional severity rating. The child is presented with a picture and is asked, “How much you are like him/her,” then he/she is provided with a five-point rated visual analog scale, which uses natural way used by children to quantify things, i.e., showing with hands how much they mean [Figure 1] and [Figure 2].
|Figure 1: Pictorial Instrument for children and adolescents for depression: Do you get like him? How much? Do you feel sad the way he does? Do people tell you that you look sad? How much? What about crying? How much does it happen to you?|
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Depression rating scales
Structured assessment scales which include clinician-rated and self-rated scales that are used for symptom assessment of depression. Many of these scales are available free of cost and can be used to assess symptoms and monitor treatment response to guide therapy [Table 1]. Response is defined as 50% reduction of symptoms on rating scales, whereas remission is defined by scores below a cutoff score.
Suicidality: Risk assessment and management
While there were concerns by pharmacological trial experts regarding risk of suicide in children prescribed with antidepressants, epidemiological studies established that the risk of suicide decreased with increased prescription of antidepressants. Initial improvement of energy levels with intake of antidepressants may increase suicidality, therefore, it is imperative to monitor and systematically assess suicidality during the initial phase of the treatment.
Incidence of suicide attempts peak during adolescence, particularly from middle-to-late adolescence. Associated depressive disorder is one of the two most important risk factors for suicide, the other being previous suicide attempt. Assessment of suicide risk is recommended to be done routinely in depressed children and adolescents. Assessment of suicidal patient includes assessment of suicidal behavior, underlying psychopathology and psychosocial contributory risk factors. Protective factors such as family cohesion, supportive atmosphere, and religious beliefs need to be considered while formulating treatment plan.
Assessment of suicidal behavior involves collection of information from parents, teachers and friends, and relatives who are close to the child. Thorough evaluation of suicidal ideation, previous planning, attempts and their lethality is essential. Use of semi-structured and structured self-rated or clinician-rated instruments has high sensitivity but low specificity. Furthermore, these scales have low predictive value for assessing suicidality. Scales cannot be used as stand-alone measures for suicide assessment and are meant to be used in addition to clinical assessment. Sample questions for assessment of suicide in children are mentioned in [Table 2].
|Table 2: Diagnostic questions about suicidal ideation (Jacobsen et al. JAACAP)|
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| Treatment of Depression|| |
Depression is managed by psychotherapy and/or pharmacotherapy in children and adolescents. Treatment is divided into acute, maintenance, and continuation phases.
Acute phase treatment aims at achieving response defined as at least 50% reduction in symptoms. This period may range from 2 weeks to 2 months.
It is aimed at consolidation of gains achieved in acute phase and prevention of relapse.
It is defined as recovery phase where the aim is to prevent any recurrence of depressive symptoms.
| Psychotherapy|| |
Psychosocial management of depression in childhood remains the mainstay. A diagnosis of major depressive disorder (MDD) as per DSM5 needs either depressed mood or loss of interest or pleasure with at least five other biological, affective, somatic, and cognitive symptoms for a period of at least 2 weeks [Table 3]. Mild depression is defined as few symptoms in excess of diagnostic criteria for MDD, minimal distress, and impairment [Figure 3]. In cases of mild depression without suicidality or psychosis nonspecific psychotherapy for 1–4 weeks may be sufficient to produce relief.
|Figure 3: Diagnosis and severity of major depressive disorder as per DSM5|
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- Psychoeducation: Psychoeducation refers to education of patient and family members about symptoms of depression, its causes, risk factors for depression, course, available treatment modalities and risks, and benefits associated with various treatments. Patient and family members are guided toward establishing a collaborative relationship wherein they are expected to contribute toward their own treatment. Depression is presented as a medical illness rather than a weakness of personality, so that the behavioral problems of the child are understood as symptomatic manifestation of depression rather than manipulation or fault of personality. The natural course of depression as a chronic, recurring, and relapsing illness is focused on wherein parents are taught to provide ongoing monitoring of symptoms and support. Parental expectations are being addressed and need for treatment adherence emphasized. Parents are also advised to supervise medication intake and to keep medication stock in their custody. Appropriate limit setting is also taught in which parents are guided toward maintaining their giving in or being excessively punitive
- Supportive psychotherapy: It includes skill of empathic listening, reflecting, general problem-solving, and advice. Problem-solving may include help and guidance in studies, problems in school, relationship issues, and conflicts with parents and teachers. Coping skills in terms of different cognitive adaptive ways of handling conflicts need to be taught. Advice about behavioral activations such as remaining busy with activities, exercising, regular sleep, and eating healthy.
- Cognitive behaviour therapy: Uses a collaborative approach in which the patient is taught to identify thoughts and mood. Negative/distorted thought identification is taught to the patient, alongside, skills for testing these thoughts, and replacing them with more adaptive thoughts. Furthermore, behavioral activation, problem-solving, and emotion regulation skills are taught to manage depression
- Interpersonal therapy: It helps patients to identify problems in relationships, interpersonal conflicts, transition in roles and teaches skills of interpersonal problem-solving, and improves communication patterns. This therapy form is very effective in adolescents because conflicts with family members and friends are very common and play as risk factors in causing depression.
| Pharmacotherapy|| |
DSM5 provides diagnostic criteria for depression in adults, which remain the same in children and adolescents [Table 1]. Severe MDD as per DSM5 is defined as a disorder in which number of symptoms is substantially in excess of diagnosis of MDD and is associated with severe distress and severe impairment in functioning. Moderate MDD is something in between mild and severe MDD [Figure 3]. Pharmacotherapy in addition to psychotherapy is indicated in moderate-to-severe depression. Furthermore, in cases of high risk for suicide, presence of psychotic features or treatment resistance, pharmacotherapy is indicated.
Choice of medications
Medications are chosen on the basis of evidence base, patient characteristics, developmental level, severity of depression, chronicity, response to treatment, family history of response, comorbid psychiatric and medical conditions, and patient and family expectation and preferences.
Only few selective serotonin reuptake inhibitors (SSRI's) are approved for use in children and adolescents. The evidence base for various SSRIs is depicted in [Table 4]. The response rate to SSRI's is 40%–70% with a number needed to treat (NNT) at 10. SSRIs are generally well tolerated in children and are associated with manageable side effects such as gastrointestinal symptoms (nausea, changes in appetite, and heartburn) and sleep changes (insomnia, hypersomnia, vivid dreams, and nightmares). Uncommon symptoms include behavioral activation such as irritability, agitation, and impulsivity, which usually are time limited and can be managed with care and support. The number needed to harm with SSRIs is 112 which is ten times that of NNT. Efficacy of SSRIs definitely outweighs harm caused by them. Suicidality is currently understood to be correlative with SSRIs rather than having a causal association; family history of suicide, patient's history of suicide, severity of depression, presence of impulsivity, and increased susceptibility to side effects because of genetic makeup might be the contributory factors. Current understanding of suicide in the context of childhood and adolescent depression recommends continuous monitoring of suicidality, provision for ongoing support and adequate treatment of depression with SSRIs and psychotherapy. Longitudinal studies have documented decreasing trends of suicide with increase in antidepressant prescription. However, links between FDA warnings on antidepressant prescription with resultant effect on suicidal behavior remains questionable.
- Fluoxetine: Fluoxetine is the first choice among all SSRIs for childhood depression owing to its efficacy, low cost, and side effect profile. Three randomized controlled trials (RCTs) have reported on the efficacy of fluoxetine in children and adolescents with MDD. FDA has approved for children and adolescents above 8 years of age. Long half-life of fluoxetine prevents rapid serum level drops upon missed doses and hence is devoid of discontinuation effects. Till date, only fluoxetine has been studied for its effectiveness in acute and continuation phases. Whereas, no data are available on maintenance phase. In few situations, other SSRI might be chosen as in cases where there is a history of lack of response to fluoxetine, issues of drug–drug interaction or strong family history of response to other SSRI
- Other SSRIs: Escitalopram is the FDA approved for treatment of adolescent depression (age ≥12 years), and till date, there are two RCTs which have reported on efficacy of escitalopram in adolescent depression. Sertraline and citalopram have shown some efficacy for depression in adolescents. Only one RCT till date has shown the efficacy of sertraline and citalopram for adolescent depression, hence these antidepressants have not yet received the FDA approval for children and adolescents with depression. Paroxetine has not shown any benefit in RCTs involving pediatric depression; on the other hand, there are safety concerns and occurrence of severe discontinuation symptoms owing to its short half-life.
| Practical Issues in Prescribing Medications|| |
Ongoing education about depression is an essential component of its management. Education about efficacy of medications and side effects with focus on ensuring compliance should be carried out. Routine monitoring of suicidal ideation, planning, and behavior consists of evidence-based practice of depression management. Symptom severity should be assessed every 1–2 weeks after initiating antidepressant medication. Primary caregiver should be entrusted with the responsibility of ascertaining compliance and supervision of medication intake. Transient side effects such as nausea and dry mouth can be managed with reassurance. Severe and distressing side effects might warrant dose reduction, slow titration, switching to an antidepressant with lower side effect profile and dietary advice, and exercise for weight gain.
SSRIs are started at the lower end of therapeutic dose and dose increase or medication change is done only after 4 weeks. In case of partial or complete remission of symptoms, the same dose of SSRI should be continued in the continuation phase. In case of minimal improvement of symptoms, dose should be increased. If there is no substantial improvement even at 12 weeks or intolerable side effects, change of SSRI is warranted.
- Phases of treatment: Treatment with antidepressants is usually divided into three phases.
- Acute phase: Aim is to achieve response which is defined as significant reduction or disappearance of symptoms for 8–12 weeks. Many RCTs have evaluated the efficacy of SSRIs such as fluoxetine and escitalopram in acute phase, wherein the target is symptom reduction
- Continuation phase: Aim is to consolidate the treatment gains and prevent relapse, the duration ranges from 6 to 12 months. Relapse defined as an episode of depression which meets DSM5 criteria for MDD. Only few controlled studies have addressed this phase, which demonstrates efficacy of fluoxetine in preventing relapse when continued at the dose given in acute phase
- Maintenance phase: Aim is to prevent relapse by continuing treatment in children or adolescents having recurrent/severe/chronic disorder. This period beyond 12 months which aims are preventing recurrence has never been addressed in any trial.
Some children would not show adequate response to antidepressants. In such an instance, it is prudent to reevaluate the diagnosis, look at comorbidities, assess if psychosocial therapy is adequately provided. There might be a need to restrategize the psychotherapeutic interventions from supportive psychotherapy to more directive approach like cognitive behavior therapy (CBT) of interpersonal therapy. Assessment of recent stressors, family relationships, and school functioning alongside evaluation of medication needs to be done.
The Treatment of SSRI-Resistant Depression in adolescents (TORDIA) trial reported clinical improvement in adolescents by a combination therapy. In adolescents not responding to antidepressants prescribed for 2 months, combination of CBT and switch to another SSRI was better than antidepressant or CBT alone. SSRIs were as effective and safer than venlafaxine (an SNRI) used for treatment-resistant depression.
Augmentation is used when the child is showing some response to antidepressant and is used as a treatment strategy without switching the antidepressant. It is usually used in cases where there is no intolerance to an antidepressant, wherein another medication is added to the antidepressant. The TORDIA trial showed addition of a mood stabilizer such as lithium or valproate, atypical antipsychotic to an SSRI increased the remission rates in resistant cases. No other medication has been used as augmenting agent in children and adolescents. The American Academy guidelines for pharmacotherapy of childhood depression is illustrated in [Figure 4].
|Figure 4: Guidelines for management of major depressive disorder (adapted form practice parameter American academy of child and adolescent psychiatry)|
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Antidepressants were conventionally thought to be associated with suicidal thoughts. However, association of suicide rates with antidepressant prescription using observational study concluded that higher SSRI prescription rates were associated with lower risk of suicide in children. Hence, adequate treatment of depression has the potential to reduce rates of suicide in children. Suicide risk assessment and addition of CBT to fluoxetine reduces the risk of suicide in children and adolescents as established in Treatment for Adolescents with Depression Study.
| Treatment Outcomes: Long Term|| |
Combination of fluoxetine and CBT is regarded as having maximum efficacy and safety. In addition, functionality, quality of life, and relapse prevention at 12 weeks are also documented to be significantly more in the combination therapy group.
| Conclusion|| |
Childhood depression is similar and at the same time different from adult depression. Assessment in the pediatric population needs to take psychological and cognitive development into account. Fluoxetine has the best evidence in the pediatric population. Combination therapy of fluoxetine with CBT has best-proven benefits.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Suravi Patra
Department of Psychiatry, AIIMS, Bhubaneswar, Odisha - 751 019
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]