Depression is the most common diagnosis given to children in the mental health clinical setting.1 The typical age for depression onset is ages 14 to 15 with onset earlier in girls than boys.2 Approximately 7.6% of children ages 12 and over have had depression with moderate to severe symptoms.1 Major depressive disorder (MDD) is associated with an increased risk of suicide, suicide attempts, early pregnancy, and decreased academic performance. It is estimated that only 36% to 44% of children and adolescents with depression receive treatment, leaving the majority of children and adolescents with depressive symptoms untreated.2
Acknowledging that very little empirical literature is available on diagnosing depression in preschool children, a growing body of empirical data supports the existence of clinically significant depression in children as young as age 3.3 Persistent depression symptoms characterized by anhedonia (such as lack of reactivity or brightening in response to joyful events and psychomotor retardation) were reported in 75 of 266 preschoolers ages 3 to 6.3,4
The purpose of this article is to assist with identifying and treating children and adolescents who present with symptoms of depression in the primary care setting. In 2010, suicide was the second leading cause of death for individuals ages 12 to 17.5 A nationwide survey of youth reported that 13% of students self-reported they had a suicide plan, and 8% self-reported trying to take their own life in the 12 months preceding the survey. The most frequent means were firearm, suffocation, and poisoning.5 Girls report more depression than boys; however, nearly five times as many boys ages 15 to 19 die from suicide.5
The Youth Risk Behavior Survey 2013 showed 17% of 9th to 12th graders reporting they had seriously considered attempting suicide in the previous 12 months, with 13.6% having a plan and 8% reporting an attempted suicide.6 The survey also indicated that children and adolescents with MDD have increased medical costs compared with children who do not have depression.6
Depression presentation and assessment criteria
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the assessment criteria for depression includes: 2 weeks of persistent change in mood (sad or irritable); loss of interest in pleasurable activities; appetite changes; changes to weight or failure to gain weight; changes in sleep; decreased activity, energy, or concentration; negative statements about self-worth; excessive guilt; and/or suicidal thoughts or attempts.7 When suspecting depression, an acronym suggested by Guidelines for Adolescent Depression in Primary Care (GLAD-PC) is SIGECAPS: sleep, interest, guilt, energy, concentration, appetite changes, psychomotor agitation or retardation, suicidality.8
Adolescents tend to have more mood swings because of hormonal changes associated with this developmental stage of life. It is important to distinguish between normal highs and lows of mood and behaviors and moods and behaviors that are representative of depression. It is important to determine if the mood change is present nearly every day for at least a 2-week period and that this presents a significant change from the adolescent or child's usual mood.7
Anger and irritability of depression are linked to an individual's method of coping and can compound the depression due to negative reactions to this behavior from parents and teachers. Anger and irritability serve as warning signs and are associated with increased suicidal tendencies, violent behavior (whether the anger was internalized or externalized by the child or adolescent), and reduced impulse control. It is important, therefore, to consider the coping style of children and adolescents who demonstrated anger as a symptom of depression. The Great Smoky Mountain Study, a longitudinal study of 1,420 9- to 16-year-olds, concluded that 58.7% youths had depressed mood, and 35.6% had depressed mood with irritability.9 Irritability as a symptom of depression presented more often in the younger youths, indicating earlier depression onset.9
Ask children and adolescents about risk factors for depression, such as divorce, bullying, drop in academic grades, alcohol and substance use, self-mutilation, and change in personality (such as irritability or anger). Although sadness is most often associated with depression in adults, adolescents more often present with anger, irritability, decline in academic grades, and negative statements about themselves with more acting-out behavior and risk-taking.10 Asking about thoughts of self-harm or suicide does not "plant" the idea. Ask adolescents if they have a plan for suicide and assess the feasibility of the plan. Seek immediate help from a mental health provider or the nearest ED to provide mental health evaluation if the plan is imminent.10
Obtain a comprehensive medical/psychiatric history
Other warning signs of depression include headaches, stomachaches, and unexplained fatigue (not attributed to a physical source or trigger). Rule out alternative diagnoses, such as anemia, malignancies, hypothyroidism, mononucleosis, or another viral condition. Inquire about past mental health counseling, including inpatient psychiatric admissions. Due to the strong genetic and inherited components of depression, inquire about family history of depression, anxiety, and other mental health disorders in siblings, parents, grandparents, aunts, and uncles. Children of parents who commit suicide are at greater risk of committing suicide.11
Major studies
The U.S. Preventive Services Task Force (USPSTF) revaluated the evidence on screening and treating children and adolescents for MDD.12 The current recommendation of the USPSTF reaffirms the previous recommendation of 2009: to screen for MDD in adolescents, ages 12 to 18, when it is possible to provide an accurate diagnosis, psychotherapy, and adequate follow-up.2,12 The current recommendation does not recommend any specified therapies. The newest USPSTF report indicates that there continues to be insufficient evidence to make a similar recommendation for screening children ages 7 to 11.2,12
Treatment for Adolescents with Depression (TADS) was the single largest clinical trial of adolescents with depression.13 It was funded by the National Institute of Mental Health (NIMH), designed to provide information on short- and long-term interventions for adolescents diagnosed with MDD. The study evaluated the acute phase of depression for 12 weeks. It compared the effectiveness of cognitive behavioral therapy (CBT), fluoxetine, and a combination of both CBT and fluoxetine. The study concluded that fluoxetine with CBT was most effective followed by fluoxetine alone; CBT alone was less effective.13
TADS followed up 1 year later and reported the adolescents continued to benefit from treatment. Adolescents from the TADS study were followed up for 5 years to evaluate the treatment's effectiveness. Almost all participants (96.4%) recovered from their episode of MDD during the follow-up period.
However, in the recovery and recurrence study of depression conducted by Curry and colleagues, sponsored by NIMH, of the 189 participants who recovered, 88 (46.6%) of the adolescents had a recurrence of depression, while 101 (53.4%) remained without depression.14 As with the TADS study, adolescents receiving both a selective serotonin reuptake inhibitor (SSRI) along with CBT therapy had improved response rates.14
The study Treatment of Resistant Depression in Adolescents (TORDIA), funded by the National Institutes of Health (NIH), reported that about 40% of adolescents do not adequately respond to the first antidepressant treatment course.15 TORDIA was conducted at six regional clinics with 334 adolescents ages 12 to 18. The adolescents were diagnosed with MDD and had not responded to an SSRI in the previous 2-month course of treatment.15
The adolescents were randomly assigned to one of four groups: current SSRI changed to a different SSRI; current SSRI changed to a different SSRI plus CBT; current SSRI changed to venlafaxine; or current SSRI changed to venlafaxine plus CBT. Results showed 55% of adolescents changed to any other SSRI plus CBT responded to treatment, and 41% who were changed to a different medication only responded to treatment. Venlafaxine was not superior to SSRIs and was associated with more adverse reactions, such as skin rash and increased systolic BP.15
The Treatment of Adolescent Suicide Attempters (TASA) study, also funded by NIH, attempted to identify predictors of suicidal attempts for adolescents ages 12 to 18 years who had made a suicide attempt within 90 days and were diagnosed with a unipolar mood disorder, either MDD or dysthymic disorder.16 The 119 participants were randomized to psychotherapy, a medication algorithm based on the Texas Medication Algorithm, or a combination. Of the participants 24 experienced a suicidal event during the 6 months of enrolling in the study, with 10 having a suicidal event within 4 weeks of intake, indicating the vulnerability of adolescents during the early period of starting treatment. Child maltreatment, higher income, the number of previous suicide attempts, and White race were predictors of suicidal ideation. Positive family cohesion and adaptability were protective factors against suicide attempts.16
Medication management
The SSRI antidepressant fluoxetine is FDA approved for ages 8 and older, and the SSRI escitalopram is approved for ages 12 and older to treat pediatric MDD.17 The SSRI paroxetine failed to show adequate evidence of support for treatment, and the studies reported increased suicidal thoughts along with other significant adverse reactions.18
The serotonin and norepinephrine reuptake inhibitor venlafaxine was studied for treatment of MDD and generalized anxiety disorder and failed to show efficacy for either indication.19 The SSRIs citalopram and sertraline were studied in placebo-controlled trials, and insufficient evidence was seen to support a pediatric indication for either drug for MDD treatment.19
Family support and participation
The influence of parents and guardians is significant for a child or adolescent's mental health and can positively or negatively influence the course of treatment. Parents appreciate caution for medication dosing and being part of the decision-making process. It is ultimately the decision of the parent or guardian for treatment. Parents should be provided with information on potential adverse reactions of medications; options for managing "nuisance" adverse reactions (such as drowsiness or mild nausea); and information about the "Black Box Warning."
Parents play a substantial role in shaping the emotional health of children and adolescents. Helping parents recognize that mental health includes both family dynamics as well as genetics will shift the focus away from the child as the source of pathology and onto the family as a source to improve treatment response. NPs need to assess parents' knowledge as accurate or inaccurate expectations about the child's development. A goal is to strengthen parenting practices. Observe and assess the parents' attitudes about mental health and the child or adolescents' mental health. Assess what parents believe is their responsibility for supervising, monitoring, and dispensing medication.
Provide an explanation of depression symptoms that is specific to the child or adolescent and explain why the medication or treatment has been chosen and how it is expected to address specific symptoms. Build an alliance with the family to emphasize a desire to work with them to support symptom improvement. Parents and guardians should be provided with literature explaining depression symptoms; this will help encourage discussion with the child regarding what he or she is experiencing. Bright Futures (http://brightfutures.aap.org), a website sponsored by the American Academy of Pediatrics, provides material to parents and professionals for evaluating depression symptoms in children and adolescents.20 NIMH has fact sheets to educate parents on depression awareness.21
Other good resources for clinicians for evaluating, treating, and working with parents are found on the Reach Institute website, which provides Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit 22 available for use with permission at http://www.thereachinstitute.org/guidelines-for-adolescent-depression-primary-ca. Parents and guardians should be careful of television programs regarding mental health, which may focus on controversy and entertainment. Although the Internet is a valuable source of information, encourage parents and guardians to seek out reliable sources of information, such as the National Alliance on Mental Illness or the American Academy of Child and Adolescent Psychiatry.23-25
Patient/family education
In 2004, the FDA first issued the Black Box Warning that antidepressants may increase the risk of suicidal ideation and behavior in some children and adolescents with MDD and reissued the statement in 2007.26 Children and adolescents taking an SSRI should be closely monitored for worsening depression and emergence of suicidal thinking or behavior. Additionally, NPs should monitor for changes in behavior, such as sleeplessness, agitation, or any other change in behavior.
Lu and colleagues reviewed the effects of the Black Box Warning with prescription use and suicide.27 After the warning, antidepressant use by adolescents declined by 31%. The authors concluded that although completed suicides are rare, attempted suicides increased by about 21.7% during this same time period.27 Evidence shows that undertreated mood disorders can have severe negative consequences. After a review of current literature on the relationship between drugs and suicidal events, the authors conclude that little evidence exists that drugs increase the risk of suicide and related behavior. They also concur that the greater risk is an inadequate depression treatment.27
A collaborative approach: Barriers to treatment
The USPSTF identified two instruments that demonstrated good sensitivity and specificity in the primary care settings for adolescent depression: the Patient Health Questionnaire for Adolescents (73% sensitivity, 94% specificity) and the Beck Depression Inventory for Primary Care (84% to 90% sensitivity, 81% to 86% specificity).2,12
There continues to be a gap despite the recognized need to identify and treat adolescent and childhood depression. A review of the literature finds primary care clinicians are aware that many children have mental health concerns, but they do not treat all disorders. A random sample of Massachusetts primary care pediatricians responded to a self-report survey. Although many primary care providers would like to refer to mental health professionals, 98% report obtaining a timely appointment is a barrier.28 Regarding treatment, the most recent national study found that a majority (60%) of U.S. pediatricians do not treat children and adolescents with MDD.12 Prescribing SSRIs by primary care has decreased approximately 22% since 2004 and can be associated with an increase in suicide rates in children and adolescents by 14% between 2003 and 2004, which is the largest year-to-year change in suicide rates in this population since the CDC began systematically collecting suicide data in 1979.12
Most pediatricians did not want to initiate medication for anxiety (87%) or depression (85%). Only 22% were reluctant to manage medications for attention deficit hyperactivity disorder.29 Another survey conducted by Nationwide Children's Hospital in Columbus, Ohio, reported 54% of primary care providers are uncomfortable diagnosing depression. Most primary care providers (9 out of 10) believe it is their responsibility to identify depression in their adolescent patients, but surveys show nearly 1 in 5 feel it can be treated in primary care.30 Family NPs (96) and pediatric NPs (54) were included in a survey of 537 clinicians for depression screening and managing adolescents with depression. Most (92%) felt responsible for identifying depression, but 26% believed they should be responsible for treating and managing depression. The majority (94%) believed they should be responsible for specialty referral.30
Nonmedication treatment suggestions
Children and adolescents who are unable to name their mood or feelings and are frustrated with attempts to label their feelings pose a dilemma for diagnosing MDD. American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters pointed out any evaluation should be sensitive to the developmental level of the child or adolescent, as this contributes to their difficulty verbalizing feelings, and therefore, they often incorrectly deny feeling depressed.31
A self-report mood diary that has statements such as, "I say something nasty to the person," "I use strong gestures such as waving my arms, making a fist," "I slammed a door, hit something," "I was sad," "I wanted to cry," or "I felt out of control" matched with corresponding pictorial faces next to the statements facilitated identifying feelings.31 Anger can be tracked using the Anger Scale. Adolescents respond to statements such as "I was easily annoyed or irritated," "I experienced outburst of anger that I could not control," "I wanted to break or damage things," and "I yelled at somebody or threw things."31
Children and adolescents can use a Likert scale to measure their feelings and behaviors from (1) "never" to (4) "often." A self-report mood diary helps educate the adolescent to identifying moods; monitor and compare daily moods; evaluate their coping skills for managing anger and irritability; allow them to explore their behaviors; and implement healthy coping skills. The AACAP recognizes the value of parents to improve depression in children and adolescents.31 Parents monitored their child's motivation for treatment, and therefore, treatment contracts involve them as they serve as a safety net.32
CBT
The TADS, TORDIA, and TASA studies all demonstrate the benefit of CBT as a psychotherapy that is beneficial for adolescent depression. Common components of this therapy include assisting with restructuring the interpretation of events, social skills training, and problem solving.13-16 CBT asserts individuals are responding with passive or aggressive communication styles toward peers, parents, and other authority figures that is based on distorted thoughts. Participants in CBT are taught steps for effective problem solving and cognitive and behavioral strategies for mood management (for example, cognitive restructuring and relaxation). Homework assignments are given to assist in skill acquisition. The child works to improve mood by changing unhealthy patterns of thinking and by ultimately working on changing behaviors, often with the assistance of family members.32 Cognitive restructuring uses the ABCDE method.32
The first step in changing negative thoughts is to identify the A (Activating Event), which is associated with negative thoughts. In teaching the ABCDE method, the letter C (Consequences) is described next to the adolescent as the Consequences or feelings related to the Activating Event. Next, the adolescent is taught that the B stands for Beliefs, and that it is one's beliefs that lead to negative affect. The adolescent is then taught that, in order to feel better, he or she must confront these negative beliefs or D dispute them. It is explained to the adolescent that most people do not dispute their negative beliefs and are left feeling very upset, and this may lead to making unsafe decisions. The last step begins with an E, which stands for Effect. Effecting something is presented as trying to change something. Adolescents are taught while they may not be able to change the fact that a negative activating event happened, they can change the negative beliefs and feelings surrounding the event.32
Family therapy
Families can significantly influence a child's mental health. Although the child or adolescent may be the identified patient, the entire family is in distress. In family therapy, the focus is shifted away from the child and onto the family as the source of the pathology, and the family becomes the target of treatment. Among many other areas of focus, family therapy looks at each member's interpersonal interactions, communication styles, conflicts, and how they organize themselves in the family hierarchy.33
Interpersonal therapy
Therapists help adolescents improve their mood by improving interpersonal relationships. Time-limited treatment focuses on achieving specific patient goals. Interpersonal therapy (IPT) focuses on improving mood by improving interpersonal functioning and increasing social support. The therapist reviews the patient's patterns in relationships, explores capacity for intimacy, and evaluates current relationships. An interpersonal focus is identified, and treatment focuses on resolving the identified problem area and practicing interpersonal skills in sessions. IPT, originally developed for adults, has been modified for adolescents (IPT-A). This version focuses on increasing adolescents' independence and negotiating support needed from others such as parents; it also includes parental participation. The focus of therapy is to: identify the problem(s); identify events for impact to relationships; encourage effective communication; teach problem-solving techniques that are specific to the identified problem(s); practice role playing; and apply these learned techniques to real-life events.34
Moving forward
A knowledge gap currently exists in determining an accurate number of children with depression and a means for identifying these children in the primary care setting. It is hoped that when primary care clinicians become aware of the number of children needing treatment, this will encourage them to screen for depression as part of the annual physical.
Depression was the focus of a National Action Agenda for Children's Mental Health (NAACMH)35 released by the U.S. Surgeon General and the Assistant Secretary for Health, which reported that 1 in 10 children or adolescents in the U.S. suffered from mental illness severe enough to cause some level of impairment. It further concluded that, "There is no primary healthcare system in place to specifically address the needs of children."35 A face-to-face survey of 10,148 adolescents ages 13 to 17 in the continental U.S. (conducted by the Institute for Social Research at the University of Michigan) concluded in 2014, "that more than half of adolescents with psychiatric disorder in the prior 12 months did not receive any mental health care from any source within that time."36 The survey concludes that little has changed from the finding of the NAACMH study in 2001.36
Screening at urgent care visits may be impractical, but NPs are given a tremendous opportunity to screen for depression as part of a health history questionnaire or annual physical. Using such screening tools during the annual physical can identify depression in children. USPSTF recommends screening all adolescents (ages 12 to 18) in the general population.2,12
Providers can make handouts and information on mental health available in the waiting room while parents and children are waiting for a "sick visit." It may not be the time to screen for depression, but it is an opportunity to make them more aware of mental health symptoms to monitor as compared to more normal behavior and development. NPs in pediatric or family practice should consider establishing professional alliances with nearby mental health clinics. Be aware of which hospitals can treat child and adolescent depression emergencies. Know the process for in patient admission to a psychiatric hospital. If the patient is referred to a mental health clinic for treatment, care should be coordinated between providers by following up.
The problem of underdiagnosis and treatment of depression in children and adolescents could be addressed if screening and assessment became part of routine pediatric visits.13 Screening for depression requires a system in place that also ensures a positive screen for depression will be followed by an accurate diagnosis, effective treatment, and careful follow-up. Identifying depression would likely reduce morbidity and mortality, increase quality of life, reduce healthcare costs, and perhaps even prevent youth violence.
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