Children and adolescents hospitalized for the treatment of physical illness often have feelings of sadness, frustration, or irritability that represent a normal response to their experience. Common factors impacting a child’s ability to cope include disruption of routine, separation from family and peers, uncertainty regarding diagnosis and prognosis, pain related to the illness or its treatment, and fear of the illness or its sequelae. When the sadness becomes pervasive and is associated with cognitive or physiologic symptoms, however, a depressive disorder must be considered. It is incumbent on the hospitalist to distinguish normal feelings of sadness from a depressive disorder and to implement treatment when necessary.
Chronically ill children are at increased risk for developing depressive, anxiety, and eating disorders.1-5 Clinical depression has been reported to increase the risk of poor physical health in the future6 and has been associated with poor adherence to treatment regimens,7 reduced immune function,8 increased disease severity, and death due to nonadherence.9 Emerging data suggest that depression in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is associated with declining CD4 counts, accelerated disease progression, and increased mortality.10 In addition, suicidal ideation and suicide attempts are tragic consequences of depression that increases with the onset of puberty.11 Depressive disorders cause significant suffering on the part of the child and family and are generally highly treatable once they are recognized. The purpose of this chapter is to provide the pediatric hospitalist with a framework for understanding the diagnosis and treatment of depressive disorders in children and adolescents with physical illness.
While multiple theories exist regarding the pathophysiology of depression (Table 135-1), conclusive evidence of its etiology is still uncertain. The Diagnostic and Statistical Manual (DSM) bases the diagnosis of depression on a cluster of symptoms. As the DSM is atheoretical by design, it is important to note that patients who may look similar phenotypically for depression may indeed have different etiological mechanisms for their depression. As such, simply making a diagnosis of depression does not indicate the pathophysiological mechanism or the optimal treatment regimen.
TABLE 135-1 Pathophysiological Hypotheses of Depression12 ||Download (.pdf) TABLE 135-1 Pathophysiological Hypotheses of Depression12
|Mechanism ||Comments |
|Genetic vulnerability ||Based upon evidence from twin studies |
|Altered HPA axis activity ||Based upon effects of stress as a risk factor |
|Monoamine deficiency ||Based upon mechanism of action of medication treatments |
|Brain region dysfunction ||Based upon stimulation of specific brain regions reproducing antidepressant effects |
|Neurotoxic and neurotrophic processes ||Based upon concept of “kindling” and brain volume loss over course of depressive illness |
|Reduced GABAergic activity ||Based upon evidence from magnetic resonance spectroscopy and postmortem studies |
|Glutamate dysregulation ||Based upon mechanism of action of medication treatments |
|Circadian rhythm impairment ||Based upon circadian rhythm changes having antidepressant effects |
Additional factors further complicate the diagnosis of depression. First, the term depression is ambiguous and has many connotations. It may be used to describe a transient mood state or one of several clinical syndromes of varying severity. Second, because symptoms of depressive disorders are subject to developmental variation, they may present differently depending on the child’s stage of development.11 Third, because medical and nursing staff often view depression as a normal and understandable response to a chronic, terminal, or disfiguring illness, psychiatric evaluation and treatment may not be pursued.12 Fourth, patients and families may be resistant to exploring the possibility of a depressive disorder because of the perceived stigma of a psychiatric diagnosis. Last, the diagnosis of depression is made on the basis of a constellation of psychological and somatic symptoms. As somatic symptoms are commonly seen in physical illness, it is often difficult to determine whether the symptoms are related to the physical illness or to a depressive disorder.
The symptoms of depressive disorders can be divided into two general realms: psychological and somatic. Psychological symptoms include dysphoric mood, anhedonia (loss of interest in usual, pleasurable activities), feelings of helplessness or hopelessness, feelings of guilt or worthlessness, loss of self-esteem, decreased ability to concentrate, and thoughts of suicide. Somatic symptoms of depression include fatigue, sleep disturbance (insomnia or hypersomnia), appetite changes (decrease or increase), and motor restlessness or retardation (see Chapter 137 for a discussion of somatic symptom and related disorders). The hospitalist should focus on the psychological symptoms because of the frequent overlap between somatic symptoms of depression and symptoms of the physical illness.
The presentation of depression depends on the child’s stage of development, and depression in children may manifest differently from depression in adolescents. Signs of depression in children (or in older children with developmental delay) may include feelings of sadness, a depressed appearance, somatic complaints (most commonly stomachaches and headaches), separation anxiety, low self-esteem, social withdrawal, academic decline, sleep or appetite disturbances, decreased concentration, and suicidal thoughts.11
In adolescents, depression frequently presents with an irritable rather than a depressed mood. Additional symptoms commonly associated with depression in adolescents include behavioral disturbances, motor hyperactivity, feelings of being unloved, self-deprecation, tearfulness, hopelessness, low self-esteem, hypersomnia, lethargy, anhedonia, weight gain, decreased concentration, declining school performance, psychomotor retardation, feelings of being misunderstood, and suicidal ideation. Adolescents frequently do not recognize their symptoms as being part of a depressive disorder and may not report them unless specifically asked.11
The hospitalist should consider the diagnosis of depression in patients who report feelings of sadness or who appear sad or withdrawn, in patients who exhibit oppositional behavior (e.g. refusal to participate in self-care or nonadherence to a treatment plan), or in patients with a history of other psychiatric disorders (e.g. anxiety, bipolar disorder, substance abuse). Studies have estimated that 40% to 70% of adolescents with depressive disorders also meet the criteria for at least one other psychiatric disorder.11
The next step is to determine into which diagnostic category the patient’s symptoms best fit. Depressive symptoms in hospitalized children and adolescents typically fall into one of three categories, although overlap is common: adjustment disorder with depressed mood (situational depression), depressive disorder related to a general medical condition or substance, and primary psychiatric disorders, such as major depressive episode or dysthymia (persistent depressive disorder).
Adjustment disorder with depressed mood (situational depression) involves symptoms such as depressed mood, tearfulness, or feelings of hopelessness that arise in response to an identifiable stressor. Illness, hospitalization, and medical or surgical procedures are the stressors typically identified in hospitalized children. Patients frequently appear sad and tearful and may not be motivated to participate in their treatment regimens. They may describe feeling overwhelmed by their illness or its treatments and may report feeling hopelessness or fear that they will never leave the hospital. Depressive symptoms typically resolve when the stressor is removed and the patient is able to resume his or her usual routine following discharge from the hospital.
Certain medical conditions, medications, and drugs of abuse may be associated with depressive symptoms and should be considered in the differential diagnosis of depression (Table 135-2).
TABLE 135-2Common Medical and Pharmacologic Causes of Depression ||Download (.pdf) TABLE 135-2 Common Medical and Pharmacologic Causes of Depression
|Endocrine ||Infectious ||Neurologic ||Medications ||Other |
|Diabetes mellitus ||Encephalitis ||Epilepsy ||Benzodiazepines ||Drug abuse and withdrawal (cocaine, amphetamines, opiates) |
|Cushing disease ||Hepatitis ||Multiple sclerosis ||Corticosteroids || |
|Hypothyroidism ||Pneumonia ||Trauma ||Oral contraceptives || |
|Addison disease ||Mononucleosis ||Sleep apnea ||Anticonvulsants || |
|Hypopituitarism ||AIDS ||Cerebrovascular accident ||Antihypertensives ||Alcohol abuse |
|Parathyroid disorders (hyper- and hypo-) ||Chronic fatigue syndrome ||Huntington disease ||Aminophylline ||Electrolyte abnormalities |
| || ||Clonidine || |
| ||Hydrocephalus ||Ibuprofen ||Anemia |
| ||Migraine ||Ampicillin ||Failure to thrive |
| ||Neoplasm ||Tetracycline ||Lupus erythematosus |
| || ||Sulfonamides ||Wilson disease |
| || ||C-Asparaginase ||Uremia |
| || ||Azathioprine ||Porphyria |
| || ||Bleomycin || |
| || ||Vincristine || |
| || ||Cimetidine || |
| || ||Stimulants || |
A mood disorder due to a general medical condition refers to a significant and persistent disturbance in mood that is the direct physiologic effect of a medical condition. A substance-induced mood disorder is the direct effect of a medication or drug of abuse. In both disorders, symptoms may range from depressed mood or anhedonia to multiple psychological and somatic symptoms of depression. A clue to the diagnosis is a temporal relationship between the onset, exacerbation, or remission of the mood disturbance and the medical disorder, medication, or drug of abuse.13,14
Primary psychiatric disorders such as major depressive episode and dysthymic disorder (persistent depressive disorder) should also be considered in the differential diagnosis of depressive symptoms. A major depressive episode is an acute episode (at least 2 weeks) of pervasive sadness or anhedonia in conjunction with four or more other symptoms of depression such as poor appetite, weight loss, poor sleep, poor concentration, loss of energy or recurrent thoughts of death. The patient must experience significant distress or functional impairment (e.g. decline in social or academic performance), and the symptoms cannot be the direct physiologic effects of a medical condition or substance (e.g. medication, drug of abuse).15 Dysthymic disorder (persistent depressive disorder) refers to a chronically depressed or irritable mood most of the time for at least 1 year (2 years in adults), with any remission in symptoms lasting less than 2 months, in conjunction with two or more of the following symptoms: insomnia or hypersomnia, poor or excessive appetite, decreased energy, poor concentration, low self-esteem, and feelings of helplessness. The symptoms must cause significant distress or functional impairment and cannot be the direct physiologic effects of a medical condition or substance.15 Primary psychiatric disorders are more common in patients with a history of previous depressive episodes or a family history of depression.
When the hospitalist suspects depression, psychiatric consultation should be obtained if available. If unavailable, the hospitalist should complete the assessment as follows. The first step is to meet with the patient and his or her parents or guardians to obtain the following information: past individual and family psychiatric histories, description of academic performance and peer relations, and drug or alcohol use. In addition, the hospitalist should inquire about current and past psychosocial stressors, perform a mental status examination, and screen for the psychological and somatic symptoms of depression. These symptoms can be remembered using the mnemonic SIGECAPS, which refers to a prescription one might write for a depressed person (sig.: energy capsules). Each letter refers to one of the diagnostic criteria for a major or clinical depressive episode (Table 135-3).15,16
TABLE 135-3SIGECAPS: A Mnemonic for Symptoms of Depressive Disorders ||Download (.pdf) TABLE 135-3 SIGECAPS: A Mnemonic for Symptoms of Depressive Disorders
|S ||Sleep ||Insomnia or hypersomnia* |
|I ||Interests ||Loss of interest or pleasure in activities (anhedonia) |
|G ||Guilt ||Excessive guilt, worthlessness,* hopelessness* |
|E ||Energy ||Loss of energy or fatigue* |
|C ||Concentration ||Decreased ability to concentrate* |
|A ||Appetite ||Appetite disturbance (decreased or increased)* |
|P ||Psychomotor ||Psychomotor retardation or agitation |
|S ||Suicidality ||Suicidal thoughts or plans; feeling that life is not worth living |
Elements of the psychiatric history that should be elicited from both the patient and the family include current and past histories of psychiatric disorders, treatments, and medications. A personal or family history of depression predisposes children and adolescents to develop a primary depressive disorder in the face of the stress of illness and hospitalization.14,17 The mental status examination should focus on evidence of the presence of mood dysphoria, suicidal ideation, and thought disorder (e.g. hallucinations, delusions).
It is important for the hospitalist to meet with the patient and parents separately for part of the evaluation to encourage full reporting of symptoms and concerns. If they are interviewed together, the patient or parents may not feel comfortable speaking freely and may withhold valuable diagnostic information. The evaluation should include the following:
Onset, severity, and duration of symptoms.
Functioning in various domains (e.g. family, school, peers).
Burden of suffering imposed by the symptoms (e.g. depth of distress, difficulty coping).
Presence or absence of suicidal ideation.
Together, these factors help determine the type and level of depression.11
The hospitalist should obtain collateral information from as many sources as possible. Teachers, guidance counselors, and therapists may provide helpful information about the patient’s mood and level of functioning outside the hospital. Within the hospital, nurses and child life specialists may provide valuable information about the patient’s symptoms and level of functioning throughout the course of each day. Assessments of the patient’s mood at different points during the day may also assist in making the diagnosis. For example, a patient who presents with a depressed mood and withdrawn behavior during morning rounds but who appears cheerful and engaged when observed in the playroom later in the day is less likely to be suffering from clinical depression than is a patient whose depressive symptoms persist without change over the course of several days.
It is important to recognize that suicidal ideation and suicide attempts may be tragic consequences of depression in children and adolescents. If there is any concern about suicide, a risk assessment should be conducted to determine the history of previous suicide attempts, family history of suicide, exposure to family violence or abuse, level of impulsivity, accessibility to lethal agents, and presence of comorbid psychiatric disorders. For those patients deemed to be at risk for suicide, constant observation in the form of a one-to-one sitter should be implemented to monitor the patient around the clock until the patient is no longer a suicide risk or is transferred to a psychiatric hospital (see Chapter 136, Assessment and Management of the Suicidal Patient).
The management of depression in hospitalized children and adolescents varies, depending on the cause. It requires both an acute intervention in the hospital and a plan for follow-up after discharge, if necessary. If available, a psychiatric consultant can be helpful in guiding the initial evaluation and diagnosis and creating a treatment plan appropriate to the child’s developmental level that incorporates the patient and his or her family, medical and nursing staff, social workers, and child life specialists. The symptoms of depression in patients with situational depression (adjustment disorder with depressed mood) are frequently related to unexpressed anxiety or fears about the illness and its treatment, feeling “out of control,” and disruption of routine. In these cases, patients typically respond well to a combination of psychosocial and behavioral interventions, and antidepressant therapy is usually not necessary.17
Psychosocial interventions are designed to help the patient and family better understand the medical condition and its treatment and to facilitate coping with the illness and hospitalization. For example, the psychiatric consultant can help explain medical issues and treatments to children in a developmentally appropriate manner to encourage feelings of mastery and control. Supportive therapy may include engaging younger children in therapeutic play with medical toys and dolls or having older patients create a scrapbook or a mood journal to cope with their feelings related to the illness and hospitalization.18 Validating a child’s experience of sadness, fear, or anxiety may be an important component of supportive therapy. Parents should be encouraged to bring special items from home (e.g. favorite blanket, toys, pictures) to help the child feel more comfortable in the hospital. If possible, the child’s teacher should be informed of the hospitalization to help facilitate contact between the patient and friends at school. Contact with other patients can provide peer support and help the child understand that he or she is not alone.
Children and adolescents may benefit from cognitive behavioral therapy (CBT) to help them cope with depressive symptoms.18 Therapeutic goals involve working with children and parents to identify and restructure negative cognitions, develop adaptive, approach-oriented coping strategies, and increase active, positively-reinforcing patterns of behavior. For instance, children with depression and inflammatory bowel disease who received a course of CBT showed improvements in depressive symptoms, perceived control, and functioning.19 The Treatment for Adolescents with Depression Study demonstrated that combining CBT with antidepressant medication may be preferable to monotherapy when treating adolescents with major depression.20 Parents also play an important role in treatment of child and adolescent depression, and parent-focused sessions are components of some CBT interventions.21
Behavioral activation (BA), another treatment for depression, aims to increase positive environmental reinforcement in order to provide opportunities for reward and mastery experiences. For chronically ill children, increased mastery may provide a greater sense of control. BA is well validated for use with adults, and preliminary research suggests that it may improve depressive symptoms and increase hopefulness among adolescents with depression.22 Creating a daily routine can allow a medically-hospitalized child a greater sense of control and predictability during a stressful and often uncertain time. Sticker charts or other reward systems can be helpful implements for promoting BA, such that children can receive rewards for medical and other important goals during the hospitalization. Distraction and engagement in pleasurable activities, in the form of movies, visitors, and crafts projects, may also be components of BA interventions and can be helpful in alleviating depressive symptoms.
Ongoing pain may be another contributor to depression. The importance of adequately treating pain cannot be overstated. Behavioral therapies such as hypnosis, relaxation, and guided imagery can be helpful adjuncts in the management of both acute and chronic pain.
Children and adolescents with mood disorder due to a general medical condition or substance generally improve with treatment of the underlying medical condition or removal of the substance causing the depressive symptoms (medication or drug of abuse). These patients may also benefit from the psychosocial and behavioral interventions previously described.
If psychosocial and behavioral interventions fail, or if the patient’s symptoms are severe (e.g. major depressive disorder), a trial of an antidepressant medication should be considered. It is important to note that there are no controlled studies addressing the use of antidepressants in children or adolescents with physical illnesses. As most antidepressants take weeks to reach maximal efficacy, the formation of a treatment alliance with the patient and parents is crucial. Before treatment begins, a meeting should be held at which the specific target symptoms are defined and the risks, benefits, and goals of treatment are delineated. It is imperative to inform the patient and parents about side effects, dosage schedule, lag in therapeutic efficacy, and danger of overdose for each agent prescribed.18 Following discharge from the hospital, the parents should be responsible for storing and administering these medications to minimize the risk of overdose. In addition, it is important to establish outpatient psychiatric follow-up in order to assess efficacy and monitor side effects of new medications.
The choice of medication depends on several variables, including the patient’s concomitant medical or psychiatric condition, potential drug interactions with other medications, and medication side effects.23 For example, an antidepressant such as mirtazapine, with the primary side effects of appetite stimulation and weight gain, would not be the first choice for a patient with diabetes. It is important to keep in mind that certain antidepressants (e.g. tricyclic antidepressants, selective serotonin reuptake inhibitors) are metabolized by the cytochrome P-450 enzyme system and may interfere with the metabolism of other medications.17
Selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment for depressive disorders. A review of evidence-based SSRI treatments in children and adolescents is provided in Table 135-4.24 While non-SSRI treatments of depression (such as bupropion, venlafaxine, mirtazapine, and duloxetine) are used, it is recommended that a psychiatric consult be ordered when considering non-SSRI treatments in youth or when considering the treatment in youth who have failed first-line agents. A discussion of such treatments is beyond the scope of this chapter and is available in other sources.23,25
TABLE 135-4Selective Serotonin Reuptake Inhibitors26 ||Download (.pdf) TABLE 135-4 Selective Serotonin Reuptake Inhibitors26
|Medication ||Level of Evidence ||Dosage Range ||Available Forms ||Cytochrome P-450 System Isoenzyme Involved ||Selected Drug Interactions* ||Cytochrome P450 Enzyme Inhibited |
|Citalopram (Celexa) ||A ||10–40 mg qd ||10-, 20-, 40-mg tablets ||3A4 ||MAOIs, ketoconazole, itraconazole, macrolides, omeprazole ||2D6 (weak) |
| || || ||10-mg/5-mL solution ||2C19 || || |
|Escitalopram (Lexapro) ||A (Adolescents Only) ||5–20 mg qd ||5-, 10-, 20-mg tablets ||3A4 ||MAOIs, sumatriptan, cimetidine; minimal clinically significant effects on pharmacokinetic properties of other medications ||2D6 (weak) |
| || || ||1-mg/mL solution ||2C19 || || |
|Fluoxetine (Prozac) ||A+ ||5–60 mg qd ||10-, 20-mg capsules ||2D6 ||MAOIs, ketoconazole, phenytoin, carbamazepine, omeprazole, digoxin, lithium, warfarin, ritonavir, tramadol, clozapine || |
| || || ||20-mg/5-mL solution ||2C19 || || |
| || || ||90-mg time-release capsule || || || |
|Fluvoxamine (Luvox) || ||25–300 mg qd ||25-, 50-, 100-mg coated tablets ||1A2 ||MAOIs, ketoconazole, carbamazepine, omeprazole, ciprofloxacin, methadone, lithium, theophylline, warfarin, clozapine || |
| || || || ||2C19 || || |
| || || || ||3A4 || || |
|Sertraline (Zoloft) ||A ||25–200 mg qd ||25-, 50-, 100-mg tablets ||2D6 ||MAOIs, warfarin, cimetidine, phenobarbital, phenytoin, digoxin, theophylline, tramadol || |
2D6 (moderate at low doses, potent at high doses)
| || || ||20-mg/mL concentrated solution ||3A4 || || |
Citalopram (Celexa) and escitalopram (Lexapro) have very little cytochrome P-450 activity and therefore less potential for drug–drug interactions. Although baseline laboratory testing is not required, it is prudent to obtain liver function tests and a complete blood count with differential and platelets before initiating therapy.24 Initial adverse effects of SSRIs may include nausea, dizziness, drowsiness, insomnia, nervousness, behavioral activation, and memory problems. These symptoms typically abate within the first few weeks of treatment and may be minimized by starting with a low dose and slowly increasing the dosage as tolerated.
Longer-term adverse effects of SSRIs may include weight gain or loss, sexual dysfunction, and an amotivational syndrome characterized by the development of apathy, indifference, amotivation, or disinhibition.18 In addition, the hospitalist should be aware of a potentially lethal condition of serotonergic hyperstimulation known as the serotonin syndrome, which can be produced by the concurrent use of drugs that enhance central nervous system serotonin (e.g. linezolid [Zyvox], voriconazole [Vfend]). Common clinical features include altered mental status, diaphoresis, myoclonus, diarrhea, tremors, shivering, restlessness, and hyperreflexia.
The FDA issued a public health advisory requiring that antidepressant labels carry a black box warning informing patients of an increased risk of suicidal thoughts and behaviors among children and adolescents taking these medications. These potential risks should be discussed with patients and their families as part of the informed consent process,25 and balanced against clinical need. Patients who are started on antidepressant therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. If antidepressant treatment is initiated during a hospitalization, parents should be counseled to take responsibility for storing and administering these medications to minimize the risk of overdose after discharge from the hospital. In addition, it is important to establish outpatient psychiatric follow-up in order to assess efficacy and monitor side effects of new medications. Families and caregivers should be advised of the need for close observation and communication with the prescriber.26 Table 135-4 provides a list of SSRIs and dosage guidelines. Currently, recommendations for weight-based dosing are not available.
Stimulants have been used with success in the treatment of depression in adults with physical illnesses and should be considered in children and adolescents. Although these agents are approved for use in youngsters with attention-deficit hyperactivity disorder, there have been no controlled studies addressing their use in the treatment of depression in the pediatric population. Studies in medically ill adults have demonstrated improvement in depressive symptoms, including mood, appetite, and energy level. Stimulants generally have a rapid onset of action (often within days) and are relatively safe, with a short half-life. Side effects may include insomnia, agitation, anxiety, confusion, and paranoia. Stimulants should be used with caution in patients with tic disorders and Tourette disorder, because they may exacerbate tics.3,27,28
A comprehensive follow-up treatment plan should be developed for the patient and family before discharge. This may include referrals to mental health providers for outpatient psychotherapy, pharmacotherapy, family therapy, or group therapy. For children and adolescents with severe depression or suicidal ideation, transfer to an inpatient psychiatric unit or enrollment in a partial hospital program may be warranted.18 If available, at this stage of treatment, a mental health professional should be involved to assist in assessment and disposition planning.
ADMISSION AND DISCHARGE CRITERIA
Most hospitalized children who are experiencing depressive symptoms are admitted for medical reasons, therefore in most cases discharge criteria will depend upon sufficient stabilization or improvement in the medical condition that prompted admission. Psychiatric admission criteria are an imminent danger to self or others, often due to suicidal or homicidal ideation or due to severe behavioral dysregulation likely to result in harm to others. Such determinations are best made via a psychiatric consultation.
Discharge criteria for children who are medically hospitalized and have ongoing psychiatric concerns will depend upon availability of appropriate psychiatric care. These children commonly require inpatient or residential psychiatric care. In these cases, children are usually actively suicidal, very recently suicidal, actively or very recently exhibiting dangerous and aggressive behavior, or pose an imminent threat to themselves or others. Occasionally a partial hospitalization program in which children receive day treatment and return home in the evenings may be appropriate, such as in the case of major depression that significantly impairs functioning but with no active or recently active suicidal ideation. When available, a mental health professional can be helpful in evaluating and securing appropriate psychiatric disposition.
Mental health services should be incorporated into the patient’s care when depressive symptoms are recognized. Psychiatrists can provide guidance for diagnosis and treatment and help organize the multidisciplinary mental health team. Input from these specialists also assists the medical team members. The mental health team may provide guidance for proper interactions with the patient and family and insights into the interactions between depression and medical illness. They are also helpful in establishing continued mental health support after discharge from the hospital.
The diagnosis and treatment of depression in medically ill children is complex. While hospitalists can often appropriately diagnose youth and begin first-line psychotherapeutic or psychopharmacological interventions, it is important to involve a psychiatric consultation for more difficult cases. This is particularly true for cases where there is concern regarding potential for imminent harm or likelihood of needing further inpatient psychiatric treatment after medical stabilization. In some of these situations, parents insist that they should be able to take their child home and can watch them 24 hours a day if necessary to maintain their safety. In such cases, if there is concern that a child may pose danger to self or others, the appropriate disposition is to an inpatient unit.
Pediatric depression is burdensome for affected children and families as well as the healthcare system, particularly given its association with chronic illness, and can be difficult to treat. Therefore researchers have evaluated the potential for secondary and tertiary prevention, with results suggesting that evidence-based programs may be effective in preventing depression among at-risk children, such as those with a family history of affective disorders, exposure to violence, or social isolation.29 Besides being evidence-based, common factors of effective prevention programs include manualized treatment, comprehensive training for providers implementing the protocols and adherence to the manuals, and be based on cognitive-behavioral or interpersonal therapeutic approaches. Most prevention programs also work within the family environment to reduce adverse interactions and improve family functioning, which may further reduce risk of depression.29
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