Depression in Children and Adolescents

Childhood and adolescent depression is often recurrent and often continues episodically into adulthood. It often occurs with co-morbid psychiatric disorders, increased risk of suicide, substance abuse, and behavioural problems. Depression affects the whole of a person's life, impairing occupational, social, emotional and physical health, and carrying considerable stigma.¹

• The prevalence of childhood depression has been estimated to be 1% in pre-pubertal children and about 3% in post-pubertal young people.²
• Depression is experienced by twice as many adolescent females as males.²
• The prevalence appears to be increasing and affecting younger children, although this may in part be due to greater awareness and improved diagnosis.
• Children and adolescents with depression frequently have psychosocial, education and family difficulties.

Risk factors¹

• Family discord
• Bullying
• Physical, sexual or emotional abuse
• History of parental depression
• Ethnic and cultural factors
• Homelessness
• Refugee status
• Living in institutional settings

The diagnosis is often missed and there is limited evidence that primary screening tools may accurately identify depressed adolescents.³

• Often with somatic symptoms and may also have features of anxiety.
• Sometimes only presents as poor functioning at school, socially, or at home.
• It may even masquerade as bad behaviour, particularly in boys.
• Mood is characteristically much more variable and less pervasive than in adults and rapid mood swings often occur.
• The fact that children are able to enjoy some aspects of their life shouldn't preclude the diagnosis of depression.
• Features as seen in adults:
  • Low mood
  • Loss of interest
  • Socially withdrawn
  • Poor self-esteem
  • Psychomotor retardation
  • Tearful
  • Guilt
  • Anxiety
  • Lack of enjoyment in anything
• Features common in childhood:
  • Running away from home
  • Separation anxiety and possibly school refusal
  • Complaints of boredom
  • Poor school performance
  • Antisocial behaviour
  • Insomnia (often initial and middle rather than early morning wakening) or hypersomnia
  • Eating increased or decreased, particularly if associated with weight change
• Young primary school children may present with sadness and helplessness. Slightly older children with feelings of being unloved and unfairly treated. Guilt and despair may be more prominent in teenagers.
• Consider the possibility of concealed contributory factors, e.g. past child abuse, bullying.
• Parents may not always be aware of depression in their children.
• Assessment is frequently difficult and many questions may only be answered by silence or a shrug. Adolescents with conduct disorders can be manipulative and extremely difficult to assess - an urgent second opinion is frequently required.
• Always ask about suicide ideation and thoughts of self-harm:
  • Note any past attempts as about 15-20% make further attempts (males, those with conduct disorder, excessive alcohol use, hopelessness and those in local authority care are at increased risk).
  • Self-harm can be regarded as a form of communication, not always 'picked up' and sometimes difficult to decipher the teenager's exact intentions. Deliberate self-harm is common in adolescents, especially females.⁴
  • Refer urgently if the risk is considered significant.

• Because of difficulties in diagnosis, variable access to psychological interventions within primary care and current controversy about the efficacy and safety of antidepressant medication in those aged under 18 years, management is based in secondary care but with support from primary care.
• Primary care services (including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services) are appropriate for the following:¹
  • Exposure to a single undesirable event in the absence of other risk factors for depression.
  • Exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm.
  • Exposure to a recent undesirable life event where one or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child/young person.
  • Mild depression without comorbidity.
• Refer to Child and Adolescent Mental Health Services, including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists if:¹
  • Depression where one or more family members (parents or children) have multiple-risk histories for depression.
  • Mild depression in those who have not responded to interventions in primary care after 2-3 months.
  • Moderate or severe depression (including psychotic depression).
  • Signs of a recurrence of depression in those who have recovered from previous moderate or severe depression.
  • Unexplained self-neglect of at least 1 month's duration that could be harmful to the child/young person's physical health.
  • Active suicidal ideas or plans. High recurrent risk of acts of self-harm or suicide.
  • Young person or parent(s)/carer(s) request referral.
• Social interventions:
  • Addressing any sources of distress, e.g. bullying, and removing opportunities for self-harm, e.g. paracetamol at home.
• Psychological interventions:
  • Children and young people with moderate-to-severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual cognitive behavioural therapy, interpersonal therapy or shorter-term family therapy).¹
  • Encourage the patient to talk about their fears and anxieties. Counsellors, sympathetic teachers and youth workers may be a suitable resource.
  • Psychological treatments, including cognitive behaviour therapy, have been used extensively, and are effective in mild or moderately severe depression. Where available, psychological treatments are often used as a first-line treatment, particularly in younger adolescents and children. However, little evidence exists to support their use in young people with more severe depression.⁵
• Medication:
  • Antidepressant medication should only be used in combination with concurrent psychological therapy.¹
  • Tricyclic antidepressants are not useful in treating depression in pre-pubertal children and there is only marginal evidence to support the use of tricyclic antidepressants in the treatment of depression in adolescents.⁶
  • A recent study found that antidepressants of all types showed limited efficacy in juvenile depression, but fluoxetine may be more effective, especially in adolescents.⁷
  • Fluoxetine should be prescribed as this is the only antidepressant for which trials show that benefits outweigh the risks.¹
  • Consider the use of another antidepressant (sertraline or citalopram are the recommended second-line treatments).¹
  • Paroxetine, venlafaxine, tricyclic antidepressants and St John's wort should not be used.¹
  • SSRIs, particularly fluoxetine:
    • Have generally been considered the first choice medication because of potential toxicity, especially in overdose, associated with tricyclic antidepressants.⁸
    • However, there have been concerns that SSRIs may increase the risk of suicidal thoughts and self-harm in young people.³
    • Fluoxetine is now the only selective serotonin reuptake inhibitor for which the Committee on Safety of Medicines considers the balance of risks and benefits to be favourable, although it cautions that the drug is likely to be beneficial in only a minority of patients, e.g. those for whom psychological therapies have failed or if the depression is life-threatening.⁹
• Electroconvulsive therapy (ECT):¹
  • Only consider ECT for young people (12-18 years) with very severe depression and either life-threatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments.
  • ECT is used extremely rarely in young people (12-18 years) and only after careful assessment by a practitioner experienced in its use, and in a specialised environment.
  • ECT should not be used in the treatment of depression in children (5-11 years).

• About 10% of children and young people with depression recover spontaneously within 3 months.
• 50% remain clinically depressed at 12 months and 20-30% at 2 years.¹
• Persistent depression in young people appears to have a permanent effect on personal function and personality.¹
• About 30% of young people with depression have recurrences within 5 years and many of these develop episodes into adult life.¹
• Female sex, increased guilt, previous episodes of depression, and parental psychopathology are associated with a worse prognosis.¹⁰
• A third of young people who experience a depressive episode will make a suicide attempt and 3-4% will die from suicide.¹¹

• Preventative psychological and educational interventions may be effective but have not yet been fully evaluated.¹²