Pediatric Behavioral-Mental Health: Depression produced by Pamela Chen, Magdalena Ivanova, Brenna Chase and Katelin Blackburn.
Depression. Even though we became familiar with the diagnosis and treatment of depression
in medical school, pediatric depression often remains stigmatized and undertreated.
By the end of this video, our hope is that you will be able to
describe the prevalence of pediatric depression in children and adolescents,
apply the American Academy of Child and Adolescent Psychiatry or AACAP guidelines, the American
Academy of Pediatrics or AAP guidelines and DSM-5 criteria to screen for and diagnose patients
with depression, initiate, titrate and discontinue antidepressants for unipolar pediatric depression,
and describe the common and serious adverse effects of antidepressants.
Epidemiology. Studies estimate that the risk for depression increases as we age. While only 2%
of children between the ages of six and 11 years old report ever having depression,
that number rises to eight to 11% for those 12 to 17 years old. This prevalence varies by gender,
however, with boys more commonly being diagnosed with depression than girls in childhood,
a difference that after puberty flips to mirror adult two to one, female to male lifetime
prevalence gender ratios. Children treated for major depression than typically have depressive
episodes that lasts longer for eight to 13 months compared to adolescents four to nine months.
For both age ranges, about half of these patients will experience a relapse or
recurrence of their depression later on with wide ranges and estimates between 20 to 70%.
Multiple studies in the United States indicate that roughly 40% of children
and adolescents with depressive disorders are not treated.
Screening and diagnosis. As the prevalence of depression increases in adolescence and can have
significant impacts on a child's health and well being the AACAP, the AAP, and the US Preventive
Task Force guidelines recommend universal annual screening for depression starting at 12 years.
The AAP also recommends targeted screening starting at 10 years for patients with risk
factors for depression, such as family history of psychiatric illness or substance use disorders,
patients with significant psychosocial stressors, such as trauma, abuse, neglect,
or foster care, or patients with frequent somatic complaints. There are several screening tools for
depression. The AACAP recommends the use of the Patient Health Questionnaire 2-items survey,
or PHQ2, which simply asks, over the past two weeks, how often have you been bothered by
any of the following problems: little interest or pleasure in doing things, feeling down, depressed,
or hopeless. This is scored with a zero to three-point Likert scale ranging from not at all
several days more than half the days to nearly every day. One study found that a cut off of three
on the PHQ2 is associated with the 74% sensitivity and 75% specificity for a diagnosis of depression.
Other screening tools include the PHQ9 which is modified for teens. The full 25-item Strength
and Difficulties Questionnaire, or the SDQ, and the short mood and feelings questionnaire.
Ultimately, though depression cannot be diagnosed through a screening form. It requires thorough
careful evaluation. Depending on the presenting symptoms, along with the full history and physical
exam, it may be important to send a CBC, chemistry, TSH, and/or a urine tox screen.
Pediatric unipolar major depression is then diagnosed using the same DSM-5 criteria as
that used for adults. At least five of the following symptoms for two weeks
with at least one of those symptoms being depressed mood or Anhedonia
with no history of mania or hypomania and symptoms not better explained by another medical condition.
To quickly review our mnemonic DSIGECAPS, D, stands for depression or irritable mood or
dysphoria. S, stands for sleep changes, hyper- or insomnia. I, stands for interest or pleasure
loss and almost all activities, also known as Anhedonia. G, stands for guilt or worthlessness.
E, stands for energy loss or fatigue. C, stands for concentration loss, impaired thinking
or indecisiveness. A, stands for appetite or weight changes. And P, stands for psychomotor
agitation or retardation. And the second S, stands for suicidal ideation or behavior.
To receive a diagnosis, these symptoms must cause significant
distress or functional impairment for the child, which could be evidenced by the declining
academic participation and performance corroborated by the patient's teachers,
interpersonal dysfunction with friends and family, and a spectrum of social-emotional reactions from
children varying from clinging to others for constant reassurance, withdrawing socially,
or actively pushing others away, and making negative assumptions of others' intentions.
For those with comorbid conditions such as ADHD, further difficulties with concentration
must align with mood symptoms for that particular symptom to score on the DSM-5.
Additionally, it is important to note any particular stressors or triggers for the patient's
current depressive episode for optimal treatment, while realizing that the presence of a stressor,
even bereavement does not mean this as an adjustment disorder with depressed features
or grief response rather than depression, if the symptoms are severe enough, as described above.
Treatment. Successful treatment requires collaboration with patients and their
families and should occur in the least restrictive setting, depending on the severity of illness and
any safety concerns. Initial treatment with a combination of pharmacotherapy and psychotherapy
has been shown to be more effective than either approach alone. By promoting coping skills and
adaptive behaviors, Cognitive Behavioral Therapy in particular has been shown to be widely
efficacious among adolescents with depression, and is an important adjunct to pharmacotherapy.
Prior to starting pharmacological treatment, it is important to discuss the medication's indications,
risks, benefits, side effects and the expected lag of therapeutic onset. This can help to establish
a therapeutic relationship, set expectations, and decrease the risk of discontinuation of therapy.
Selective serotonin reuptake inhibitors, or SSRIs, are the most commonly used antidepressants
in children. There are currently only two FDA-approved SSRIs for pediatrics.
Fluoxetine, or Prozac, for ages eight and above, and Escitalopram, or Lexapro for ages 12 and
above. The first line of treatment for children and adolescents with depression is fluoxetine.
Sertraline, escitalopram, citalopram, and venlafaxine are reasonable second
line agents for patients that do not respond to fluoxetine.
Paroxetine is generally not used as it has not demonstrated efficacy in the pediatric population.
In adolescents, we start fluoxetine at 10 milligrams per day for one week, and titrate
up to a target dose of 20 milligrams per day. If there is inadequate response after three weeks and
the drug is tolerated, the dose can be increased to 40 milligrams per day. In children, we initiate
fluoxetine at five milligrams per day and titrate up to a target dose of 10 milligrams per day.
If response is insufficient after three weeks, the dose can be increased to 20 milligrams per day.
Please refer to the chart for the starting dose and target dose of other SSRI options.
After initiation of pharmacotherapy patients should be monitored weekly for the first month,
bi-weekly for the next month and then monthly. During follow up visits, it is important to
assess for symptomatic improvement, side effects, and satisfaction with treatment.
Adverse effects typically occur within days to weeks of starting a medication or increasing
the dose. As most adverse side effects of antidepressants are most severe in the early
treatment, while their benefits are appreciated later on, it is common for many families to
discontinue medications before they have an adequate chance to work. Thus, it is important
to provide families with information regarding side effects and their expected time course.
Common side effects of SSRIs include: sleep changes, such as insomnia or sedation, GI-upset,
such as abdominal pain, nausea, and diarrhea, sexual dysfunction, and restlessness.
It is also important to be aware of, and monitor, for the more serious adverse effects of SSRIs.
One potential serious side effect of SSRI use is serotonin syndrome. Serotonin syndrome is a
potentially life-threatening condition caused by over stimulation of serotonin receptors, leading
to agitation, delirium, diaphoresis, tachycardia, hypertension, muscle rigidity, and hyperreflexia.
In severe cases, it can lead to seizures, arrhythmias, and death. While still possible,
the risk of serotonin syndrome is low when using a single serotonergic drug.
The risk increases with the use of other serotonergic medications,
including other antidepressants, triptans and dextromethorphan, a cough suppressant.
Another risk of SSRI use is suicidality. The FDA issued a blackbox warning regarding the
risk of increased suicidality when starting antidepressants in children and adolescents.
When considering the use of antidepressants, the risk of antidepressant related suicide
must be considered alongside the risk of suicide associated with untreated depression.
After the blackbox warning was issued, the decline in antidepressant prescriptions
and children was accompanied by 14% increase in adolescent suicide rates.
Furthermore, data for multiple trials suggests a number needed to treat a three to six for
efficacy compared to a number needed to harm of 143. With this data in mind, the consensus
among most mental health specialists is that the benefits of antidepressants outweigh the risks.
Typically, 70 to 80% of patients show a response to treatment.
If a patient does not respond to treatment, despite therapeutic dosing, then it is important
to reassess the diagnosis, evaluate for comorbid conditions, such as a substance use disorder,
and assess for additional stressors and side effects that may be impeding adherence.
Once these factors have been addressed, a reasonable strategy is to change to a
different antidepressant and add psychotherapy, if the patient is not already attending.
Now that we have talked about treatment options and monitoring, let's discuss a common question
that patients have: "How long should treatment continue?" Treatment of pediatric depression can
be divided into an acute phase and maintenance phase. The acute phase aims to induce remission
of symptoms and typically lasts six to 12 weeks. The goal of the maintenance phase
is to prevent relapse and typically lasts 16 to 20 weeks, although the length is variable
depending on the severity of illness, family preference, and number of previous relapses.
In general antidepressant therapy is recommended for one year after a first episode of depression,
two years after a second episode, and indefinitely for those with three or more episodes.
Discontinuation of antidepressant therapy should be performed slowly and with close monitoring.
An exception to this rule is fluoxetine. Fluoxetine has a long half-life and can
be discontinued abruptly without adverse effects.
Other medications with short half-lives should be tapered before discontinuation.
A typical taper schedule includes decreasing the dose by 25 to 50% per week.
This wraps up our brief introduction to the epidemiology, diagnosis, and treatment of
pediatric depression. As a quick review, the key learning points from this video are as follows:
The prevalence of depression increases with age, with about 10%
of adolescents reporting a history of depression. The AACAP and AAP recommends universal screening
for depression with the PHQ-2 starting at age 12. The DSM-5 criteria for diagnosing depression
is similar for all age groups. One important difference is that in children and adolescents,
but not adults, persistent irritable mood can count as a criterion. Combination treatment
with pharmacotherapy and psychotherapy is the most effective. Prior to starting
pharmacological treatment. It is important to discuss the medication's benefits,
indications, risks, side effects, and the expected lag of therapeutic onset.
Fluoxetine is the first-line pharmacological option. Patients should be monitored on a
weekly basis for the first month after initiating therapy. And adequate trial of antidepressants is
six to 12 weeks, followed by a maintenance phase of at least 16 to 20 weeks. Except for fluoxetine,
most antidepressants should be slowly tapered down to avoid withdrawal symptoms.
Hopefully, this video has been helpful to you. We hope you come away with a
better understanding of depression in pediatric patients and feel equipped to identify symptoms,
use tools to make the diagnosis, and initiate treatment management with families.