Depression

Key Features

Essentials of Diagnosis

• Dysphoric mood, mood lability, irritability, or depressed appearance, persisting for weeks to months at a time

• Characteristic neurovegetative signs and symptoms (eg, changes in sleep, appetite, concentration, and activity levels)

• Suicidal ideation, feeling of hopelessness

General Considerations

• Clinical depression can be defined as a persistent state of unhappiness or misery that interferes with pleasure or productivity

• Incidence of depression in children

  • Increases with age, from 1% to 3% before puberty to around 8% for adolescents

  • Higher when other family members have been affected by depressive disorders

  • Equal between sexes in childhood

  • With the onset of puberty the rates of depression for females begin to exceed those for males by 5:1

• Lifetime risk of depression ranges from 10% to 25% for women and 5% to 12% for men

Clinical Findings

• Typically, a child or adolescent with depression begins to look unhappy and may make comments such as "I have no friends," "life is boring," "there is nothing I can do to make things better," or "I wish I were dead"

• Behavior patterns change from baseline and can include social isolation, deterioration in schoolwork, loss of interest in usual activities, anger, and irritability

• Sleep and appetite patterns commonly change

• Child may complain of tiredness and nonspecific pain such as headaches or stomach aches

Diagnosis

• The American Academy of Pediatrics recommends annual screening for depression in children age 12 and older using a standardized measure

• Depression often coexists with other mental illnesses, such as

  • ADHD

  • Oppositional defiant disorder

  • Conduct disorder

  • Anxiety disorders

  • Eating disorders

  • Substance abuse disorders

• Depressed adolescents should also be screened for hypothyroidism and substance abuse

Treatment

Nonpharmacologic

• Cognitive-behavioral therapy

  • Improves depressive symptoms

  • Focuses on building coping skills to change negative thought patterns

  • Helps identify, label, and verbalize feelings and misperceptions

Pharmacologic

• Fluoxetine (Prozac)

  • Usual starting dose: 10 mg/d (60 mg max); recommend decrease maximum dosage by around one-third for prepubertal children

  • Increase increment (after about 4 weeks): 10–20 mg; recommend using the lower dose increase increments for younger children

  • FDA approved for depression in children: Yes (> age 8)

  • Long half-life, no side effect from a missed dose

• Citalopram (Celexa)

  • Usual starting dose:10 mg/d (40 mg max); recommend decrease maximum dosage by around one-third for prepubertal children

  • Increase increment (after about 4 weeks):10–20 mg; recommend using the lower dose increase increments for younger children

  • FDA approved for depression in children: No

  • Few drug interactions

• Sertraline (Zoloft)

  • Usual starting dose: 25 mg/d (200 mg max); recommend decrease maximum dosage by around one-third for prepubertal children

  • Increase increment (after about 4 weeks):25–50 mg; recommend using the lower dose increase increments for younger children

  • FDA approved for depression ...