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Depression in children and adolescents

This document provides an overview of mood disorders with a focus on depression. It defines major types of depressive disorders according to DSM-5 criteria including major depressive disorder, persistent depressive disorder, disruptive mood dysregulation disorder, and others. For major depressive disorder, it outlines diagnostic criteria including required symptoms and describes mild, moderate and severe types. It also discusses epidemiology, clinical course, differential diagnosis, comorbidities, sequelae, etiology and risk factors, protective factors and prevention strategies, screening tools, and management approaches including psychotherapy and medication options.

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Depression- A Mood Disorder Mood Disorders are interrelated sets of psychiatric symptoms characterized by a core deficit in emotional self-regulations. 1. Depressive Disorders -Dysphoric [Low Mood] 2. Bipolar Disorders -Dysphoric Euphoric [High Mood]
DEPRESSION-TYPES (DSM-5) • MAJOR DEPRESSIVE DISOREDERS • PERSISTENT DEPRESSIVE DISORDER • DISRUPTIVE MOOD DYSREGULATION DISORDER • OTHER SPEICIFIED/ UNSPECIFIED DEPRESSIVE DISORDER • PREMENSTRUAL DYSPHORIC DISORDER • SUBSTANCE/ MEDICATION INDUCED DISORDERS
MAJOR DEPRESSIVE DISORDER • DSM-5 CRITERIA: 5 OR MORE SYMPTOMS + AT LEAST 2WEEKS DURATION + CHANGE FROM PREVIOUS FUNCTIONING SYMPTOM THAT MUST BE PRESENT- ( at least 1) 1. DEPRESSED MOOD OR 2. LOSS OF INTEREST OR PLEASURE
MAJOR DEPRESSIVE DISORDER contd. SymptomsList Vegetative symptoms- 1. Disturbed appetite 2. Disturbed sleep 3. Disturbed energy level 4. Disturbed Activity level Cognitive Symptoms- 1. Impaired concentration 2. Thoughts of Worthlessness or excessive & inappropriate guilt feeling, Feeling of Helplessness and Hopelessness (COGNITIVE TRIAD) 3. Suicidal thoughts or actions
MAJOR DEPRESSIVE DISORDER contd. • Types: Mild- Few or no, symptoms in excess of those required to make the diagnosis. Mildly distressing, manageable, mild functional impairment. Severe- Symptoms substantially in excess of those required to make the diagnosis. Highly distressing, unmanageable, markedly impair function. Moderate- intermediate severity.
PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) • Depressed or Irritable mood for at least 1 year (for children and adolescents). • Chronic form of depression having vegetative and cognitive symptoms. • Cognitive symptoms are less severe. Eg., low self esteem rather than worthlessness; hopelessness rather than suicidality. • Types- Mild, Moderate, Severe ( Same as MDD)
PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) contd.
MDD and Dysthymia • Overall clinical presentations in children and adolescents are same as adult. • Prominence of symptoms can change with age-  Irritability and somatic complaints more common in children  Energy, activity level, appetite and sleep disturbances more common in adolescents
DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) • Severe, Persistent IRRITABILITY FOR at least 12 months in multiple settings- at HOME, at SCHOOL, with PEERS. • Frequent and Severe temper outburst- verbal &/or physical • Persistently irritable and angry mood for most of the day, nearly everyday NB- Oppositional Defiant Disorder (ODD) and intermittent Explosive Disorder (IED) have some similar characteristics but in milder form.- Both diagnosis cannot coexist with DMDD. Conventional Hierarchical Diagnostic Rules apply for DMDD,BPD,ODD,IED- as symptoms overlap. BPD>DMDD>ODD & IED
DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) contd. DSM-5 CRITERIA FOR DMDD
OTHER SPECIFIED/UNSPECIFIED DEPRESSIVE DISORDER • Sub-syndromal depressive disorder • Symptoms characteristic of depressive disorder and cause clinically significant distress or functional impairment. • Do not meet the full criteria for any of the disorders in this diagnostic class.
EPIDEMIOLOGY • The overall prevalence rates of childhood depression in India vary anywhere between 0.3% to about 1.2%. The NMHS (2015-16) reported a prevalence rate of 0.8% (CI 0.3–1.4) for depression among 13–17 year-old children. (WHO 2017) • Male : Female ratio approximates 1:1 in childhood; early adolescence rises to 1:1.5-3.0.
CLINICAL COURSE • May first appear at any age but likelihood of onset increase markedly with Puberty. • Course is quite variable- some rarely or never experience remission, others experience many years with few or no symptoms between episodes. • Dysthymia has often early and insidious onset. • Prepubertal age group exhibit more heterotypic than homotypic continuity (Mostly in adult), ie. Depressed children develop nondepressive psychiatric disorder in their adulthood. • Adolescents has Homotypic continuity, recurrence probability 50%-70%. • Severe symptoms, longer time to remission, maltreatment, comorbid psychiatric disorder- NEGATIVE PROGNOSTIC FACTORS. • 20% of depressed adolescents develop BPD.
DIFFERENTIAL DIAGNOSIS • MEDICAL CONDITIONS- Neurologic disorders Endocrine disorders Infectious Diseases Tumors Anemia Uremia Failure to thrive Chronic fatigue disorder Pain disorder • MEDICATIONS- Narcotics Chemotherapy Beta Blockers Corticosteroids Contraceptives PSYCHIATRIC CONDITIONS- Autism Spectrum Disorder ADHD Bipolar Disorders Anxiety Disorders Trauma and Stressor related Disruptive/Impulse control/Conduct disorder Substance related disorders
COMORBIDITY • 40%-90% Youth with Depressive disorders have other psychiatric disorders, and up to 50% have 2 or more comorbid diagnosis. • Most common comorbidity- ANXIETY DISORDER • Other common comorbidities- ADHD, DISRUPTIVE BEHAVIOUR, EATING & SUBSTANCE USE. • DMDD can be co-occurred with other depressive disorder, ADHD, Conduct disorder, substance use
SEQUELAE • 60% Youth with MDD report thinking about suicide and 30 % actually attempt. • Risk of Suicide increases if- history of attempts, exposure to adverse psychosocial circumstances, family history of suicidal behaviour, comorbid psychiatric disorders. • High risk of- Substance abuse, Impaired family and Peer relationship, Early Pregnancy, Legal problem, Educational and Occupational achievement, Poor adjustment to life stressors. • Children with DMDD have displayed elevated rate of Social impairment, School suspension, Service use.
ETIOLOGY AND RISK FACTORS • Vulnerability grounded in gene by environmental pathways. • 2-4 fold bidirectional increase among 1st degree relatives & 40-65% concordance in monozygotic twins. • Biologic Risk Factors- Cerebral variation in structure & function ( particularly serotonergic) Variation in HPA axis function Difficult temperament/personality (negative affectivity) Ruminative, Self-devaluating cognitive style • Psychosocial factors- Physical/sexual abuse Neglect Chronic illness School difficulties (bullying, academic failure) Social isolation Family/Marital disharmony Divorce/Separation Parental psychopathology Domestic violence
PROTECTIVE FACTORS AND PREVENTION • Protective Factors- Positive Relationship with a parent Better family function Closer parental supervision/monitoring/ involvement Prosocial peer group Higher IQ Greater educational aspirations • Prevention- Psychosocial and Educational strategies Various programs to provide information about the Link Between Depressed Mood and Depressogenic thoughts and Behaviour and training in skills intended to modify these thoughts and behaviour
SCREENING/CASE FINDING • Targeted Screening Strategy- Known High Risk Groups: Homeless, Refugees, Involved with child welfare or Juvenile Justice Youth experiencing known psychosocial adversities Self reporting a dysphoric mood • Various Standardized Screening Tools- Broadband: 1. Paediatric Symptom Checklist 2. Strengths and Difficulties Questionnaire 3. Vanderbilt ADHD Diagnostic Rating Scale Narrowband: 1. Beck Depression Inventory 2. Patient Health Questionnaire-9
DETECTION OF DEPRESSION IN ADOLESCENTS IN NONSPECIALIST SETTINGS
MANAGEMENT • Stepped Approach- by Active Case Finding & Initial Management. • High rates of response to Placebo and Attention Comparators. EARLY INTERVENTION Paediatric practitioner assesses Onset, Duration, Context & Severity of Symptoms If acute dangerousness (E.g. Suicidality, psychosis, substance abuse) and significant distress/ functional impairment ABSENT Follow up in 1-2wks to conduct depression assessment using a depression screening instrument If Mild Symptoms- GUIDED SELF-HELP (Anticipatory Guidance) with watchful waiting Additional follow up visits to follow the progress If continued mild symptoms- Supportive Psychotherapy- individual or group format focusing on Teaching Thoughts (E.g. Positive self talk) and Behaviour ( Pleasurable activities, relaxation, problem solving, effective communication)
MANAGEMENT Contd. • Not responding to 4-6 wk of Supportive Psychotherapy • Moderate to Severe, Comorbid or Recurrent Depression • Suicidality • History of Mania, Traumatic Exposure Severe Family Dysfunction • Psychopathology Assessment and Treatment in the specialty Mental Health Setting by a Child-trained Mental Health Clinician
MANAGEMENT Contd. • Moderate to Severe Depression Specific Manualized Psychotherapies Antidepressant Medication Combination of the two • Goal of acute treatment phase- Achieve Response, i.e., at least 50% reduction in depressive symptoms as assessed by a Standardized Rating Scale • Ultimate Treatment Goal- Full Recovery, i.e., Absence of a Depressive diagnosis.
MANAGEMENT Contd. Specific Manualized Psychotherapies Cognitive Behavioural Therapy (CBT)  Identifying & Correcting Cognitive Distortions  Teaches problem solving  Behaviour Activation  Social Communication  Emotional regulation skills Interpersonal Therapy decrease interpersonal conflicts  Enhancing Interpersonal Problem Solving  Social Communication Each of these involves approximately 8-12 weekly visits Family Therapy Though little evidence is available regarding it’s effectiveness, some suggest that it’s better than NO THERAPY
MANAGEMENT Contd. ANTIDEPRESSANT MEDICATIONS 2 Selective Serotonin Reuptake Inhibitor (SSRI) is approved for Depression as 1st line agent- 1. FLUOXETINE (greater efficacy) 2. ESCITALOPRAM. In preadolescents only FLUOXETINE is approved. If there are comorbidities, side effect to 1st line agents, personal or family history of response to specific medication- alternate options are- 1. SERTRALINE 2. CITALOPRAM. 60% of patients respond, 30% among them experience symptom remission.
MANAGEMENT Contd. Side-effects: 1. MC- Irritability, GI disturbances, Sleep disturbances, Dizziness, Change in appetite, Dry mouth. 2. Behavioural activation- particularly in children- Increased Impulsivity, Agitation, Irritability. 3. Serotonin Toxicity- Bleeding, Arrhythmia (Citalopram causing dose- dependent QT prolongation), increased suicidal thoughts. Initial dose is approximately half of adult dose (e.g., 10mg of Fluoxetine) Treatment should be continued for 6-12months- as there is high rate of recurrence All antidepressants should be discontinued gradually to avoid WITHDRAWAL SYMPTOMS ( GI upset, Disequilibrium, Sleep disruption, Flu-like symptoms, Sensory disturbances)
MANAGEMENT Contd.
Depression in children and adolescents