Childhood Depression .pptx

Childhood Depression .pptx

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  Childhood Depression. Moderated by: Dr.Mitthat Miglani Presented by: Dr. Arshika Garg
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  Introduction • Depressive disordersin childhood represent a significant public health concern, in that they are prevalent and result in long-term adverse effects on the individual’s cognitive, social, and psychological development. • Prevalence increases with age, with a notable rise during adolescence. • Symptoms often differ from adults and may present as irritability, academic decline, somatic complaints, or social withdrawal. • Early identification is crucial, as untreated depression increases the risk of recurrence, functional impairment, and suicide in later life.
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  History: • Children werebelieved to be incapable of experiencing true depression prior to the 1900s. • In the 1930s and 1950s, emotional problems in children were believed to be behavioral issues or reactions to their environment. • In the 1960s and 1970s, researchers confirmed that children could experience clinical depression similar to that of adults. • In the 1980s, childhood depression was officially recognized in diagnostic manuals (DSM-III) • In the 1990s: early detection, school-based support, therapy, and family involvement. • Crucial Shift: From denial to acknowledgment to prevention and early intervention
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  Contributions of HenryMaudslay: Henry Maudsley (1835–1918): One of the first psychiatrists to say that kids can get depressed • He challenged the idea that only adults could get depressed • He said that mental illness has biological and developmental roots • He said that emotional problems in childhood could last into adulthood • His ideas laid the groundwork for modern child and adolescent psychiatry • Effect: Maudsley's work helped psychiatry move toward seeing depression as a real problem in children.
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  Discovery: • Early 20thcentury: The diagnosis of childhood depression was mainly rejected. • The general consensus was that children were not emotionally mature enough to experience true depression. • Melanie Klein (1930s): Although not as a formal diagnostic entity, she was among the first to describe depressive states in children within psychoanalytic theory. • In the 1970s, Leon Cytryn and Donald McKnew presented systematic clinical and research evidence that childhood depression exists and is similar to adult depression in developmentally modified forms. • Major depressive disorder in children was officially recognized by psychiatry in the DSM-III (1980).
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  EPIDEMIOLOGY • The prevalenceof depression in children and adolescents suggest that the prevalence varies according to the different age groups. • Prevalence figures reported for infants vary from 0.5% to 3% in clinic population • Preschool children, the prevalence rate for major depression (1.4%) has been reported to be higher than depression not otherwise specified (0.7%) and dysthymia (0.6%). • Studies done in community settings suggest the prevalence of depression in children to range from 0.4% to 2.5% and among adolescents to be from 0.4% to 8.3%. • Lifetime prevalence through adolescence is considered to be as high as 20%. Prior to puberty,
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  Onset • Although depressioncan strike at any age, it is rare before the age of six because of a lack of emotional and cognitive development. • Late childhood to early adolescence (10–14 years) is the typical age of onset. • During puberty, the incidence significantly rises and is linked to: Neurobiological alterations (hormonal changes, activation of the HPA axis)
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  Gender • Prepubertal childhood:comparable prevalence in boys and girls Some studies have reported slightly higher rates in boys, which are frequently associated with behavioral presentations. • Depression is known to have equal gender representation; however, among adolescents, the male: female ratio is 1:2 • Hormonal changes associated with puberty raise the risk in females. • Girls are more vulnerable due to psychosocial factors like body image, interpersonal stress, and rumination. • Gender disparities continue into adulthood.
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  CLINICAL PRESENTATION • TheDSM-5 uses the same criteria for major depressive disorder in youth as in adults, except that for children and adolescents, irritable mood may replace a depressed mood in the diagnostic criteria. • The core features of major depression in children, adolescents, and adults bear a striking resemblance; however, the developmental level of the child or adolescent influences the clinical presentation. • Infants may manifest as failure to thrive, severe psychomotor delay, apathy, sad facial expression, and lack of responsiveness to alternative caregivers • Very young children with major depression are sad, listless, or apathetic, even though they may not articulate these feelings verbally, Instead, these children may have irritability, which may manifest as frustration and temper tantrums and behavioral problems.
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  • Younger childrenwith depression more often manifest with somatic symptoms (headache, abdominal pain, and general aches and pains), anxiety features (separation anxiety and phobias), restlessness, and psychotic symptoms such as hallucinations. • Adolescents with depression often report symptoms of anhedonia, boredom, hopelessness, increased sleep, weight change (including failure to reach appropriate weight milestones), substance use including alcohol, and suicide attempts • Psychotic symptoms in Depression: are thematically consistent with depressed mood, occur with the depressive episode (usually at its worst), and do not include certain types of hallucinations (such as conversing voices and a commenting voice, which are specific to schizophrenia). • Depressive hallucinations usually consist of a single voice speaking to the person from outside his or her head, with derogatory or suicidal content. Depressive delusions center on themes of guilt, physical disease, death, nihilism, deserved punishment, personal inadequacy, and (sometimes) persecution. • These delusions are rare in prepuberty, probably because of cognitive immaturity, but are present in about half of psychotically depressed adolescents.
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  • Diagnostic andStatistical Manual, fifth revision (DSM-5) and International Classification of Diseases, 11th Revision, depression must be diagnosed in children and adolescents by using the same diagnostic criteria, as used for other age groups. • The DSM-5 suggests that the criteria of “presence of depressed mood” can be replaced by “irritable mood” in children and adolescents. • The diagnosis of persistent depressive disorder (equivalent of dysthymia) requires duration of 1 year in contrast to the 2-year duration required for adults. • However, it is considered that the criteria given in the DSM do not address the developmental variations in symptom manifestations, and hence it is required to modify the criteria to pick up depression in children. Diagnostic criteria
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  • Depressive episodesare relatively rare in childhood • • All the characteristic features of a depressive episode can be observed in children and adolescents. As in adults, symptoms of a depressive episode should represent a change from prior functioning. • Assessment of a depressive episode in younger children in particular is likely to rely on the report of other informants (e.g. parents) regarding signs and symptoms and the extent to which these represent a change from prior functioning. • Affective cluster • In young children, depressed mood may present as somatic complaints (e.g. headaches, stomach pains), whining, increased separation anxiety or excessive crying. Depressed mood may sometimes present in children and adolescents as pervasive irritability. • However, the presence of irritability is not in and of itself indicative of a depressive episode and may indicate the presence of another mental, behavioural or neurodevelopmental disorder, or be a normal reaction to frustration. ICD-11 diagnostic criteria
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  • Cognitive-behavioural cluster:As noted, reduced ability to concentrate or sustain attention may manifest as a decline in academic performance, increased time needed to complete school assignments or an inability to complete assignments. • These symptoms of a depressive episode must be differentiated from problems with attention and concentration in attention deficit hyperactivity disorder that are not temporally tied to changes in mood or energy. • Neurovegetative cluster: Hypersomnia and hyperphagia are more common symptoms of a depressive episode in adolescents than in adults. Appetite disturbance in children and adolescents may manifest in failure to gain weight as expected for age and development rather than as weight loss. • As with adults, children and adolescents experiencing a depressive episode are at increased risk of suicidality. In younger children, suicidality may manifest in passive statements (e.g. “I don’t want to be here any more”) or as themes of death during play, whereas adolescents may make more direct statements regarding their desire to die
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  • Self-injurious behavioursthat are not explicitly suicidal in terms of lethality or expressed intent may also occur in a depressive episode in young children and adolescents. Examples include head banging or scratching in young children and cutting or burning in adolescents. If unaddressed, these types of behaviors tend to increase in frequency and intensity over time among children and adolescents. • Before developing persistent depressive disorder, a child or adolescent may have experienced a major depressive episode. • A concurrent episode of major depressive disorder is far more likely to occur in a child who has had persistent depression for more than a year. • Both depressive diagnoses (double depression) apply in this situation. • It is more likely to be an adjustment disorder when minor depressive episodes occur less than three months after a major stressful life event.
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  Difference From AdultDepression Aspect Children Adults Expression of mood Anger, irritability, tantrums, or “bad behaviour” masking sadness. Loud complaints about misery. Persistent low mood, emptiness, and despair. Quieter, heavier, more sustained. Cognitive symptoms Limited ability to describe emotions. Clinginess, poor concentration, declining grades, school refusal. Clearly expressed suicidal thoughts, guilt, worthlessness, rumination, negative thinking. Physical complaints Fatigue, headaches, stomach aches. Somatic expression of emotional distress. Low energy, appetite changes, sleep disturbance. Anhedonia Loss of interest in play, hobbies, and friends. A significant warning sign. Reduced pleasure in daily activities, work, relationships, and sex. Behavioural changes Aggression, withdrawal, regression (bedwetting, thumb-sucking), school problems. Psychomotor retardation or agitation, social withdrawal, reduced productivity. Suicidality Less verbalized, more impulsive, often underestimated. More planned and verbalized, linked with hopelessness. Course & prognosis Higher risk of recurrence in adulthood if untreated. Early onset tends to persist. Variable course influenced by personality, stressors, and comorbidities.
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  Comorbidity • Up to90% of young people with depression can experience one or more other disorders. • 50% can experience two or more other disorders concurrently. • Most other disorders comorbid with depressed mood include: Anxiety disorders, such as GAD, other specific phobias, and separation anxiety disorders • Issues related to both depression and anxiety become more visible as distinct disorders occurring at the same time: With escalating levels of the disorder, also with advancing age of the child Comorbidity Other frequent comorbid disorders include: Dysthymia, conduct problems, ADHD, substance use disorders. 60% of adolescents with MDD have comorbid personality disorders, including Borderline Personality Disorder. Paths to comorbid disorders could be different for various disorders/sexes
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  ETIOLOGY •Biological :Twin studiesconsistently show higher concordance rates for depressive symptoms in monozygotic twins compared to dizygotic twins, •“Top-down” family studies indicate that children of parents with depression •A commonly studied genetic risk factor is a less functional allelic variant of the serotonin transporter gene (5-HTTLPR). •This variant is associated with early-onset depression, The 5-HTTLPR polymorphism remains one of the most frequently reported candidate gene variants linked to depression, especially within gene–environment interaction models (Caspi et al., 2010). •PSYCHOSOCIAL: family discord, Physical abuse, sexual abuse, neglect, and domestic violence ,Poor academics, difficulty concentrating, slowed thinking, lack of interest and motivation, fatigue, sleepiness and Parental Neglect
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  Course And Outcome •About one in five depressed teenagers exhibit signs of depression lasting two years or longer (Lewinsohn et al., 1998; Birmaher et al., 2000). • The duration of depressive episodes ranges between three and six months for community samples and between five and eight months for referred samples (Birmaher et al., 2002). • Risk of recurrence Within the first two years following an initial episode, there is a 30% to 70% chance of recurrent depression. • Bipolar illness It is estimated that 10–20% of people with early-onset depression will develop bipolar disorder (Geller et al., 2001).
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  Course And Outcome(cont.) Suicidalbehavior Suicidal behavior is a common sequela of early onset depression, and the mortality due to suicide is elevated at least 10-fold compared to nondepressed youth (Bridge et al., 2006). Risk factors for suicidal behavior 1. Greater severity and chronicity of depression 2. Current ideation with a plan or a history of a suicide attempt 3. A history of nonsuicidal self-injury 4. Conduct or substance abuse disorders 5. High levels of impulsive aggression 6. Family history of suicidal behavior, abuse, family conflict, and lack of support
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  Assessment Tools: • Selfand parent-report questionnaires are useful for screening for depression and monitoring treatment response and are time-efficient. • The Mood and Feelings Questionnaire (MFQ) is the only self- and parent-reported scale validated for both children and adolescents and comes in a 37-item and 13-item form, the latter of which is useful for screening for depression. • The Children’s Depression Inventory (CDI) was developed as a downward extension of the Beck Depression Inventory (BDI), has self-, parent-, and teacher-report forms, is highly correlated with other measures of depression, and discriminates depression from anxiety and disruptive disorders • The Patient Health Questionnaire-2, consisting of two items (low mood and anhedonia) has been validated as a screen for depression in adolescents, as has the longer nine-item version
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  Assessment Tools(cont.) • Threeother measures with good psychometric properties that have been used to screen for depression and to monitor treatment effects are the Center for Epidemiologic Studies-Depression Scale (CES-D; although it lacks a suicide ideation item), the BDI, and the Reynolds Adolescent Depression Scale (RADS- 2). • In a comparison of the CES-D and BDI using item-response theory, the CES-D performed better in lower ranges of symptomatology, whereas the BDI performed better at higher ranges of symptomatology. • The most common interview used in research studies in child and adolescent depression is the semi structured Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL). • The most commonly used continuous, interview-based measure of depressive symptomatology is the Children’s Depression Rating Scale-Revised (CDRS-R), a 17-item assessment that has been shown to have good reliability and treatment sensitivity
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  1.Complete History Takingand Establish Diagnosis TREATMENT 1.Complete History Taking and Establish Diagnosis 2. Evaluate for comorbidity 3. Consider the possibility of the underlying medical cause 4. Consider the possibility of Bipolar Disorder 5. Consider other psychiatric disorders in the differential diagnosis 6. Assessment for suicidal behavior 7. Evaluate the level of dysfunction 8. Evaluate the support system 9. Use of rating scales 10. Send basic investigations
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  TEARMENT PLAN
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  • Presence ofsuicidal ideas of a definite sort, or who have made an attempt of suicide in the recent past • Evidence of harm to self, threat to harm self, or threaten to harm others • Problems with medication and treatment compliance or delivery, leading to unduly protracted treatment • Need for electroconvulsive therapy • Substantial neglect of self, particularly their food intake 6. Need for removal from a hostile social environment Indications for admission in children and adolescents with depression
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  • NICE guidelines:Antidepressants are not recommended as a first‐line treatment in recent‐onset, mild depression – active monitoring, individual guided self‐help, cognitive behavioural therapy (CBT) or exercise are preferred. • Antidepressants are recommended for the treatment of moderate to severe depression and for dysthymia. When an antidepressant is prescribed, a generic selective serotonin reuptake inhibitor (SSRI) is recommended. • All patients should be informed about the withdrawal (discontinuation) effects of antidepressants. For treatment‐resistant depression, recommended strategies include augmentation with lithium or an antipsychotic or the addition of a second antidepressant • Patients with two prior episodes and functional impairment should be treated for at least 2 years. The use of electroconvulsive therapy (ECT) is supported in severe and treatment resistant depression. Pharmacotherapy
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  Pharmacotherapy(cont.) ● Fluoxetine andEscitalopram is the only agent recommended for use in adolescents by the National Institute for Health and Care Excellence (NICE) guidelines, and approved by the US Food and Drug Administration (FDA) for both preadolescent and adolescent depression. ● These two double-binded RCTs included adolescents aged 12–17 years who were treated with escitalopram 10–20 mg/day ● Antidepressants which have been evaluated in children and adolescents include imipramine, des- imipramine, clomipramine, nortriptyline, amitriptyline, fluoxetine, paroxetine, escitalopram, sertraline, duloxetine, venlafaxine, nefazodone, and mirtazapine. ● Results of RCTs of most of these antidepressants came out to be negative. ● A recent network meta-analysis, which included data on 14 antidepressants from 34 trials involving 5260 participants, concluded that only fluoxetine was significantly better than placebo. ● This meta-analysis also concluded that fluoxetine was better tolerated than duloxetine and imipramine.
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  Pharmacotherapy(cont.) ● These trialsshowed that escitalopram was superior to placebo and was well tolerated. ● One of these trials also showed that the response and remission rates were significantly higher with escitalopram. ● The Food and Drug Administration (FDA) of United States has approved the use of fluoxetine in children aged 8 years or above and use of escitalopram in children aged 12 years or above.
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  Pharmacotherapy(cont.) ● Sertraline wasefficacious in two multicenter, double-blind, placebo-controlled trials of 376 children and adolescents. ● The doses of sertraline ranged from 50 to 200 mg a day or placebo. ● Citalopram has been demonstrated in one RCT in the United States to be efficacious in 174 children and adolescents treated with citalopram at doses of 20 to 40 mg a day or placebo for 8 weeks. ● Significantly more of the group on citalopram showed improvement compared with placebo on the depression rating scale (CDRS-R). ● A significantly increased response rate (response defined as less than 28 on CDRS-R) of 35 percent occurred in the citalopram group, compared with 24 percent of the placebo group. ● RCTs to date that have not shown efficacy on primary outcome measures include those using mirtazapine and tricyclic antidepressants.
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  TADS ● The multicentricNational Institute of Mental Health-funded study, i.e., Treating Adolescent Depression Study (TADS), which compared the use of fluoxetine alone, CBT alone, or combination of both, concluded that combination of CBT and fluoxetine offered the highest treatment response rates followed by response rate to fluoxetine alone. ● The Treatment for Adolescents with Depression Study (TADS) divided 439 adolescents between 12 and 17 years of age into three treatment groups of 12 weeks, composed of either fluoxetine alone (10 to 40 mg/day), fluoxetine with the same dose range in combination with CBT, or CBT alone. ● Based on ratings of the Children’s Depression Rating Scale-Revised (CDRS-R),combination treatment had significantly superior response rates compared with either treatment alone.
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  • A multicentricrandomized study, named “Treatment of SSRI-Resistant Depression in Adolescents (TORDIA),” has evaluated 334 patients aged 12–18 years, diagnosed with major depression of moderate severity, who did not respond to an adequate trial of a selective serotonin reuptake • These patients were randomized to receive a different SSRI or venlafaxine, with or without CBT for 24 weeks. The outcome of the study was determined by using CGI-Improvement Scale and Children’s Depression Rating Scale-Revised • At 12 weeks, CBT plus switch to venlafaxine or second SSRI was found to have higher response rate than switch to medication alone. • compared to SSRIs, venlafaxine was associated with higher rise in diastolic blood pressure and pulse rate and dermatological problems. • Long-term follow-up at 72 weeks of patients recruited to the TORDIA study showed that 61.1% of the patients achieved remission. • However, compared to patients who received venlafaxine, those who received SSRI had more rapid decline in depressive symptoms and suicidal ideations as per the self-report. Treatment‑Resistant Depression
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  FDA Warning andSuicidality ● In September 2004, the FDA received information from their Psychopharmacologic Drug and Pediatric Advisory Committee indicating. ● Based on their review of reported suicidal thoughts and behavior among depressed children and adolescents who participated in randomized clinical trials with nine different antidepressants, an increased risk of suicidality in those children who were on active antidepressant medications. ● Although there were no suicides, the rates of suicidal thinking and behaviors were 2 percent for patients on placebo, versus 4 percent among patients on antidepressant medications. Antidepressants among children and adolescents cause medication-induced behavioral activation which is characterized by the symptoms : ● { irritability, agitated and aggressive behavior, anxiety symptoms (i.e., features of panic attacks), restlessness, hostility, akathisia, hypomania/mania, and emergence of psychotic symptoms}. ● Common side effects that emerged included headache, nausea, insomnia, rhinitis, abdominal pain, dizziness, fatigue, and flu-like symptoms.
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  The FDA, followingthe recommendation of their advisory committees, instituted a “black-box” warning to the health professional label of all antidepressant medication indicating the increased risk of suicidal thoughts and behaviors in children and adolescents, and the need for close monitoring for these symptoms. Several reviews since 2004, however, concluded that the data do not indicate a significant increase in the risk of suicide or serious suicide attempts after starting treatment with antidepressant drugs.
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  Psychosocial Interventions
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  • Explaining thepatient and caregivers about the signs and symptoms of depression • Explaining the patient and caregivers about the diagnosis of depression • Explaining the impact of untreated depression on school attendance and academic functioning • Explain that depression is a medical disorder which is treatable Psychoeducation
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  CBT ● CBT isan efficacious intervention for the treatment of moderately severe depression in children and adolescents. ● CBT aims to challenge maladaptive beliefs and enhance problem-solving abilities and social competence. ● A review of controlled cognitive-behavioral studies in children and adolescents revealed that, as with adults, both children and adolescents showed consistent improvement with these methods.
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  IPT ● Interpersonal psychotherapy(IPT) focuses on improving depression through a focus on ways in which depression interferes with interpersonal relationships and overcoming these challenges. ● The four main areas of focus with interpersonal psychotherapy include loss, interpersonal disputes, role transition, and interpersonal deficits. ● A modification of interpersonal therapy to more specifically address depression for adolescents (IPT- A) includes a focus on separation from parents, authority figures, peer pressures, and dyadic relationships. ● IPT-A: IPT-A has been studied on an outpatient basis as well as in a school-based clinic setting.
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  PCIT-ED ● PCIT-ED forpreschool depression, a modification of PCIT historically used in the treatment of disruptive disorders for children, was piloted in an RCT for 54 depressed preschoolers. ● PCIT-ED was manualized and consisted of three modules conducted over 14 sessions in 12 weeks. ● The focus of these modules is to strengthen the parent–child relationship by coaching parents in positive play techniques, giving effective directives to the child, and responding to disruptive behavior in firm but not punitive ways. ● The novel portion of the treatment targeting the preschool depression consisted of a 6-week Emotion Development (ED) module, which focused on helping the parent to be a more effective emotion guide and affect regulator for the child.
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  Electroconvulsive Therapy ● ECTis rarely used for adolescents, although published case reports indicate its efficacy in adolescents with depression and mania. ● Currently, case reports suggest that ECT may be a relatively safe and useful treatment for adolescents who have persistent severe affective disorders, particularly with psychotic features, catatonic symptoms, or persistent suicidality.
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  Treatment indication :
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  Treatment algorithm forcontinuation phase of depression in children and adolescents
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