Depression can be more common than asthma and other chronic medical problems in the pediatric population.1 Assessment and treatment of major depressive disorder (MDD) in children and adolescents is critical in the primary care setting.1
Depression rates rise from 3% in childhood to 14% in adolescents.2 Youth who have mental health issues are more likely than their peers to access primary care services.3 The primary care setting is an appropriate venue for screening and identifying depression, and initial management or referral to psychiatric mental health professionals for evidence-based treatments such as psychopharmacologic interventions, cognitive behavioral therapy, and interpersonal psychotherapy (IPT). Nurse practitioners (NPs) are in a crucial position to ensure that these children and adolescents receive appropriate and timely assessment, diagnosis, and treatment.
Incidence, prevalence, and risk factors
The prevalence of MDD is estimated to be between 0.4% and 2.5% of children and between 0.4% and 8.3% of adolescents.4 During adolescence, the female-to-male ratio of MDD rises from approximately equal prevalence to 2:1.5 Females trend toward more severe depression on negative mood scales, anhedonia, and decreased self-esteem, while males trend toward more interpersonal problems.6 Middle–to-late adolescence is the most common age for the first episode; earlier onset of depression appears to predict a more protracted or severe course.7,8
Ninety percent of MDD episodes resolve within 1.5 to 2 years after onset, and an episode of MDD in adolescents generally lasts 7 to 9 months.9,10 MDD is often recurrent, with 70% of adolescents relapsing within 5 years, and the number of prior episodes indicating future depression.4,8,11
Family, twin, and adoption studies indicate that genetic and environmental factors influence MDD.12 Studies of twins also show a higher heritability in adolescents than prepubertal children, suggesting that early onset depression is determined by life stressors.13,14 Depressive disorders have a familial transmission. Individuals with high genetic risk are more susceptible to negative life events and environmental factors than others.15
Environmental and cognitive risk factors also play a role in depression and include increased family conflict, low socioeconomic status, death of a parent, parental depression or divorce, physical or sexual abuse or neglect, poor peer relationships, loss of significant friendship, feelings of rejection, and perceived failure or lack of confidence.12,14,16
Positive connections to family, school, and guardians can serve as protective factors. Having high academic expectations and a healthy, nondeviant peer group also function as protective factors.17
The diagnosis of depression is confirmed when the child or adolescent exhibits depressed or irritable mood along with anhedonia (the inability to gain pleasure from activities), for 2 weeks or longer, with at least 5 symptoms consistent with depression criteria (see Depression criteria and symptomatology). These symptoms must represent a change from previous functioning and produce psychosocial impairment that is not caused by uncomplicated bereavement.18
MDD without psychotic features is characterized by the presence of most of the criteria symptoms and observable inability to function.18 A typical presentation of MDD may include increased reactivity to rejection, lethargy, increased appetite, cravings for carbohydrates, and hypersomnia.19
Adolescents with MDD tend to display more sleep and appetite disturbances, delusions, suicidal ideation and attempts, and impaired functioning than younger children, but more behavioral problems and fewer neurovegetative symptoms than adults with MDD.20 Parents often report externalizing symptoms, such as irritability, moodiness, whininess, and loss of interest; while youth report internalized symptoms, such as sadness, suicidal thoughts, and sleep disturbances.21
Physical signs of depression in adolescents include neglected hygiene, pale and tired appearance, sad or irritable affect, psychomotor retardation or agitation, impaired concentration, and diminished abstract reasoning ability for their age.21 The primary care provider (PCP) should be familiar with the components of the mental status exam and evaluate the child on each of these items (see Key points of the mental status exam).
Somatic symptoms may emerge, such as headaches or abdominal symptoms that increase before the start of the school day.16 These symptoms may not initially be recognized as psychosomatic and then only after repeated presentation with negative physical or lab findings, will they be recognized as possible symptoms of depression or anxiety. A complete and sensitive history of the physical complaints, current life stressors, and mental health history is necessary to establish a possible connection between a physical complaint and mental illness.
NPs should be aware that 40% to 90% of youth with MDD have other psychiatric disorders, with at least 20% to 50% having two or more comorbid disorders.20 Comorbidities include anxiety, conduct problems, personality disorders, substance abuse, attention deficit/hyperactivity disorder, and obesity.14,22–24 Youth with depression also display interpersonal conflicts, unfulfilling social relationships, and educational and occupational underachievement.14,24
Screening and assessment in adolescents
The U.S. Preventive Services Task Force recommends that PCPs annually screen adolescents for depression from ages 12 through 18 years during routine visits.25 Children under 12 should be evaluated for depression if the NP assesses symptoms of depression, parental concerns about the child's mood, a family history of mood disorders, or concerns about substance use. There are a variety of screening tools available, including written assessments to be completed by the parent or adolescent and interview-style assessments that can be administered by the NP (see Depression screening tools for adolescents).
Depression screening tools for adolescents include the Beck Depression Inventory-II, Patient Health Questionnaire-Adolescent Version, and Children's Depression Inventory.26–28 These tools take approximately 5 to 10 minutes to complete, and are tailored to evaluate depression symptoms and classify depressive symptom scores as mild, moderate, or severe.
The Pediatric Symptom Checklist and the American Medical Association Guidelines for Adolescent Preventive Services questionnaire (AMA,GAPS) are general screening tools for mental health disorders. The Pediatric Symptom Checklist is available online at no charge from Bright Futures (http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf). Although these tools do not identify specific mental health disorders like depression, they alert the practitioner that further assessment is necessary.
The HEADSS screening tool (Home, Education, Activities, Drugs, Sexuality, and Suicide/Depression) is a psychosocial evaluation tool for PCPs working with adolescents.29 HEADSS aids in the identification of suicide ideation and depression in teens. If a high-risk area is identified during the HEADSS assessment, further evaluation is necessary.30
When screening for depression, it is important to establish confidentiality parameters. The adolescent can be guaranteed confidentially as long as no information regarding abuse or the intent to harm self or others is disclosed, in which case the family must be included to make a plan for safety. A child who discloses any type of abuse or suicidal ideation must be referred to the local ED, and the legal guardian must be notified. In addition, abuse must be reported to the local Department of Children and Families or designated state referral agency.
Time-saving written screening tools may be completed prior to meeting with the practitioner. Interviews, while time-consuming, can be more personal, and provide the detailed information necessary to make a diagnosis of depression.31 Assessment and screening should include an interview with the child and parent separately, as either might be uncomfortable sharing information in front of the other, and may lead to omissions of information. Rating scales should be used throughout treatment to evaluate whether treatment interventions are causing a decrease in depressive symptoms.
Once rating scales, a mental status exam, and information on symptoms presentation according to the Diagnostic and Statistical Manual of Mental Disorders (DMS-IV) criteria are obtained, other components of a mental health evaluation should be completed. The assessment should include a history of the problem and family mental health history, medical history of child and family, evaluation of psychiatric comorbidities, a comprehensive social history, evaluation of the neighborhood environment, and peer relationships. School history should include current functioning, changes in functioning, grades, relationship with teachers, and support systems at school. Parental consent must be obtained prior to getting information from the child's school and current medication use and substance use should be reviewed as some adolescents try to self-medicate. One of the most important factors to assess is the child's risk status, including a suicide assessment.
In 2004, suicide was the third-leading cause of death in the United States among youths and young adults ages 10 to 24 years, accounting for 4,599 deaths.32 Suicide rates for adolescents increased by 300% from 1950 to 1990, decreased between 1990 to 2003, and then increased again after 2003.33 Shain hypothesized that inadequate treatment of depression due to a decreased use of selective serotonin reuptake inhibitors (SSRIs) in response to an FDA advisory warning may have had an unintended effect of increasing suicide risk. Olfson found that fewer than 2% of depressed youth were on medication at the time of suicide, and that a 1% increase in antidepressant prescriptions was associated with a 0.23 per 100.00 decrease in adolescent suicides.34 The TASA study evaluated the predictors of suicidal events and attempts in 124 depressed adolescents who had made a suicide attempt within 90 days of intake.35 The study was conducted over a 6-month period. The primary measure was the Children Depression Rating Scale Revised. These youth were randomized to one of three treatment conditions including psychotherapy for suicide, medication treatment, or a combination of the two treatments. Results demonstrated that 24 out of 124 youth experienced a suicidal event over the 6-month evaluation period in which 10 suicidal events occurred within 4 weeks of intake. Youth who experienced a suicidal event demonstrated a higher level of suicidal ideation at intake, a greater number of previous attempts, a higher level of self-reported depression, more feelings of hopelessness, increased borderline personality traits, a greater history of sexual and physical abuse, and more comorbid anxiety symptoms. There was no differential effect of the type of treatment on suicidal ideation. Family cohesion was protective against a suicidal event. Regardless of the reason for the increase in suicide rates, providers must actively assess adolescents for suicidal thoughts and plans, current, previous, and possible future attempts.
Two major risk factors for suicide are prior suicide attempts and the presence of one or more diagnosable mental health disorders, especially depression or bipolar disorder in conjunction with substance use. NPs should inquire about recent stressful events such as a loss of a romantic relationship, bullying, disciplinary troubles in school or with the law, as well as academic or family difficulties. It is important to note that asking about suicidal thoughts will not increase risk for suicidal behavior.36
A complete suicide risk assessment includes a family history of suicide attempts, prior suicide attempts by the individual, mental health disorders, impulsivity, environmental or family stress, family violence, history of physical or sexual abuse, interpersonal conflict, accessibility of firearms, or means to harm oneself in the home. Children and adolescents should also be asked if someone they knew recently committed suicide.36
If the adolescent is suicidal, the NP must determine if the adolescent has a plan that includes the proposed method, time, place, and available means.37 Children and adolescents with a well-thought out plan and intent are at high risk for suicide and should see a mental health specialist either in the ED, hospital, or through a same-day clinic appointment.38 Parents and adolescents should always be given emergency contact numbers when they leave the clinic for use as needed.36 The PCP should also communicate directly with ED staff to determine the findings of their evaluation and disposition of the adolescent. In such situations, guardians will be contacted as appropriate to ensure safety of the adolescent. Some clinicians prefer to make “safety contracts” with depressed youth; however, safety contracts are not legally binding, and the literature does not support the efficacy of safety contracts.
A detailed suicide risk assessment might include the following questions39:
* Have you ever felt life is not worth living?
* Do you think about your own death?
* Have you ever thought about killing yourself?
* How often do you think killing yourself?
* Have you ever tried to kill yourself? If yes, what have you tried?
* What has stopped you from hurting yourself?
* Is there someone you can tell if you feel like killing yourself?
* Do you have a plan to hurt yourself now? If so what is that plan?
A complete physical exam is crucial when evaluating a child or adolescent with symptoms of depression in order to rule out any medical causes for depressive symptoms. Organic conditions that might cause depressive symptoms include infections, and endocrine or neurologic disorders.21,40 For example, hypothyroidism may cause fatigue, and sleep and appetite changes. Chronic health conditions can result in symptoms similar to depression; major depression can occur in those with chronic health conditions. Health-related functional impairment in adolescence is a significant risk factor for depression.2
Lab tests may include a thyroid function test, complete blood cell count with differential, electrolytes, blood glucose, blood urea nitrogen, creatinine, creatinine clearance, urine osmolarity, and a liver function test.21,40 A monospot or Epstein-Barr Virus antibodies may also be considered. A pregnancy test should be performed for all sexually active adolescent females presenting with depressive symptoms.
Many medications can cause fatigue, sleep changes, and appetite changes including antihypertensives, barbiturates, benzodiazapines, oral contraceptives, cimetidine, aminophylline, anticonvulsants, clonidine, digoxin, thiazide diuretics, and SSRIs.21,40 Alcohol is also a central nervous system depressant and has been associated with 50% of suicides in youth with depression.18 Height, weight, and BP should be evaluated at baseline and again at follow-up visits.
It is important to screen children and adolescents with MDD for any symptoms of mania or hypomania. In a study by Geller et al., 20% to 40% of adolescents with MDD who initially displayed unipolar depression developed bipolar disorder within 5 years, indicating a need for follow-up.41 Therefore, the clinician should monitor for symptoms of mania and hypomania at each primary care visit (see Mania symptoms).42 Family history should also be assessed for relatives with bipolar disorder since it has a genetic component.
To define a manic episode of bipolar disorder, three (or more) symptoms must have persisted and have been present to a significant degree.18 The mood disturbance must be sufficiently severe to cause marked impairment in occupational functioning or in usual social activities and relationships with others. Hospitalization may be necessary to prevent harm to self or others.18 Youngstrom et al., evaluated six rating scales that screen for bipolar disorder in youth and found that the Parent Young Mania Rating Scale and the Parent General Behavior Inventory were more reliable than bipolar rating scales given directly to children, adolescents, or teachers.43–45
Education and treatment
The PCP can initiate treatment by explaining depression as a disease, its treatment options and prognosis, and how depression affects others.21 It is important for patients and families to understand that depression is a common psychiatric disorder and may be a chronic and recurrent condition requiring long-term treatment. The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) toolkit (www.gladpc.org) is a useful depression education resource for families.46
Evidence-based treatments for adolescent depression include psychosocial treatments, such as cognitive-behavioral therapy (CBT) and IPT, as well as pharmacotherapy, predominantly with SSRIs. All options should be considered initially and reexamined throughout treatment. Phases of treatment include the acute phase, the initial phase for which treatment optimally results in clinical response and reduced depressive symptoms; the continuation phase, in which the treatment goal is preventing relapse of symptoms; and the maintenance phase, in which the goal of treatment is to prevent new episodes or recurrence of depression.47
Psychosocial therapy can be used as first-line treatment for mild-to-moderate depression, a first episode of mild-to-moderate depression, and in cases where there are identifiable psychosocial stressors implicated in the development of depression, such as parental divorce, death of a friend or family member, or dissolution of a romantic relationship. CBT and IPT have both been shown to be effective in adolescents with mild-to-moderate depression and should be tried for at least six to 12 weeks.1
CBT has demonstrated effectiveness in adolescent depression.48 The goal of CBT is to teach skills to manage and reduce depressive thoughts, and behaviors by monitoring and controlling one's mood.1 CBT interventions begin with education about depression and continue with mood monitoring, scheduling pleasant activities, cognitive restructuring, and improving social, communication, and conflict resolution skills.48 Cognitive restructuring may involve replacing negative thoughts and attributions, such as self-blame or criticism, with positive, more realistic affirmations.
In the continuation and maintenance treatment phases, the CBT to prevent relapse (RP-CBT) model is useful.47 Additional skills included in RP-CBT training are emotional regulation, social skills, assertiveness, and relaxation training.
In the study, “Treatment of SSRI-Resistant Depression in Adolescents,” those with MDD who did not respond to a course of SSRIs were separated into groups for second-line treatment with an alternative SSRI or venlafaxine (Effexor), with or without 12 weeks of adjunctive CBT. There were more favorable results for adolescents treated with CBT plus second-line medication versus those who received only second-line medication.49 Adolescents who had more than nine CBT sessions were 2.5 more times likely to have an adequate response than those with fewer sessions.50
IPT is a theoretical approach that addresses grief, interpersonal dispute, role transitions, interpersonal deficits, and other family and relationship problems.48 The goals of IPT include enhancing communication skills in significant relationships and decreasing depressive symptoms via improved understanding of self, ability to problem solve, and improved communication.36
Similar to adult psychotherapy, IPT for adolescents further addresses developmentally specific issues to teens, such as changes in parent–child roles, while developing effective coping strategies including improved communication, expression of emotions related to changes in relationships, and the development of new and effective social support systems. The course of treatment is 12 individual sessions, 30 to 60 minutes each, over a 12-to-16-week period.48 Although PCPs do not usually perform IPT or CBT, they can apply several principles of these modalities. PCPs can teach adolescents to engage in more pleasurable activities by making a schedule of realistic goals for each week, practicing positive thinking, and performing brief, 5-minute sessions with parents and youth to rehearse communication and negotiation strategies.21
While psychosocial interventions are a first-line strategy, the adolescent's depression symptoms, severity, and presence of neurovegetative symptoms, such as poor sleep and appetite, may warrant consideration of selective antidepressant medications. Further, medication may be considered first-line therapy in an adolescent with MDD whose symptoms are disabling, who has had a prior episode of MDD, who exhibits chronic symptoms and suicidal tendencies, or has a family history of MDD that has responded well to pharmacotherapy.21
SSRIs are a primary psychopharmacologic treatment intervention for adolescent depression. Treatment should begin at a lower starting dose and gradually increase to an optimal therapeutic level to avoid unfavorable side effects and to make sure that the adolescent does not develop suicidality or agitation. Careful monitoring for agitation, suicidal ideation, or worsening depression should be evaluated with dose increases. Fluoxetine (Prozac) is a good first-line antidepressant for adolescents and an FDA-approved medication for the treatment of depression in children and adolescents ages 8 to 18 years. Sertraline (Zoloft) and citalopram (Celexa) have demonstrated effectiveness in research studies, but they are not FDA approved for depression in children and adolescents. In addition, a more recent study has also found escitalopram (Lexapro) to be effective and well tolerated in treating adolescents between 12 and 17 years, and has been FDA approved.51
Research comparing the use of fluoxetine to CBT has shown that both fluoxetine and CBT have similar positive outcomes by 18 to 24 weeks of treatment, but a faster response can occur with fluoxetine.47 Thus, a teen in acute initial treatment may benefit from several weeks of medication before CBT is added, as the medication may provide the energy level and concentration to participate actively in CBT. The Treatment of Adolescent Depression Study (TADS) in 2004 had four study arms: fluoxetine alone, CBT alone, fluoxetine with CBT, and placebo. Findings demonstrated that the combination of fluoxetine and CBT was the most effective treatment in both response and remission rate.52
When considering SSRIs for treatment, practitioners have expressed reservations about the FDA's “black box” warnings of increased risk for suicidal thinking and behavior in adolescents. The FDA evaluated 23 studies that included 4,300 children and found 4% of all children and adolescents taking medication had adverse effects of agitation and suicidal ideation compared to 2% of the placebo patients.53
Studies evaluating the suicidal risk with SSRIs have shown the benefits of the drug outweighs the risks.52,54 A study of data from 588 regions in the United States between 1990 and 2000 evaluated the relationship between changes in antidepressant medication treatment and suicide in adolescents, and found that antidepressant medication actually decreased suicidal behavior.34 Another study of national suicide data, in conjunction with prescribing data, county by county, found that an increased number of prescriptions was associated with a lower suicide rate in children, effectively demonstrating antidepressant efficacy, treatment compliance, and better quality mental healthcare.55 Further, CBT used with fluoxetine has a beneficial effect on suicidal ideation and self harm.52
Fluoxetine once daily dosing may begin at 10 mg daily to avoid adverse effects. An increase in dose is typically made after one week. However, monitor lower weight children (due to increased drug plasma levels) at the initial dose for several weeks, and if there is no improvement, the dose may be increased to 20 mg per day. Patients taking fluoxetine should be seen once a week, at minimum, to assess risk for suicidal ideation, agitation, and worsening depression.56 The once daily starting dose for escitalopram is usually 10 mg in adolescents. The dose can be increased to 20 mg per day for a maintenance treatment after at least 3 weeks, with the starting dose of 10 mg per day.
The adolescent should be encouraged to give the medication a fair trial as it may take 4 to 6 weeks before the intended effect takes place.57 CBT and IPT should be adjuvant therapies as needed.
At the start of antidepressant medications and during dose changes, clinicians should look for any unusual changes in behavior, worsening depressive symptoms, increased agitation or anxiety, and suicidality upon initial treatment and at dosage changes. Clinicians should teach caregivers how to monitor children for these effects and educate children that the medication may cause headache or abdominal discomfort initially, but this typically subsides within a few weeks.
Maintenance antidepressant medication is recommended for 1 year to prevent recurrence. Treatment-resistant depression is defined as a less than 50% improvement as measured by rating scales such as the Children's Depression Rating Scale revised. If the PCP does not see more than 50% improvement in symptoms after medication dose adjustment or medication switch, a search for the underlying cause for nonresponse is warranted. Nonresponse may be caused by inaccurate initial diagnosis, comorbid psychiatric conditions, medical problems, severe psychosocial stressors, lack of adherence, inadequate drug dosage, or an inadequate length of the trial. The patient should be referred to a psychiatric APRN (Advanced Practice Registered Nurse) or MD for reevaluation of psychiatric diagnosis, medication options, and psychosocial treatment. While adults with depression have responded to augmentation with lithium, bupropion, atypical antipsychotics, or electroconvulsive therapy, these treatments have yet to be tested in randomized controlled trials in youth.
When to refer
Once the patient is diagnosed with depression, the NP should consult with a psychiatric NP or psychiatrist to determine the best course of treatment to ensure appropriate level of care. Mild depression can be managed through education, mood monitoring, supportive psychotherapeutic interactions, cognitive-behavioral strategies, coping skills training, and medications such as SSRIs.25
Ongoing suicide risk assessments should occur at each visit. Rating scales can be administered to assess for objective improvement or decline in functioning from the baseline ratings, and the same assessment tool should be used at each visit. If there is suboptimal improvement in depression symptoms, problems with adherence to treatment, and the presence of comorbidities, a referral should be made to a mental health specialist.46
For adolescents with moderate-to-severe depression or complicating factors, such as comorbid psychiatric conditions including bipolar disorder or signs of mania, or severe psychosocial stressors, GLAD-PC recommends consultation or referral to a mental health specialist and following evidence-based practice guidelines for treatment.46,57 Other reasons to refer include chronic recurrent depression, coexisting substance abuse, high level of family discord, recent suicide attempt, suicide ideation, or the presence of psychosis.1
Implications for practice
PCPs should routinely screen for depression in adolescents and must rule out medical and pharmacologic causes of depression, referring the patient to mental health specialists as needed. PCPs and NPs must be aware of diagnostic criteria for depression in the DSM-IV, as well as some of the widely used depression screening tools, and should be familiar with therapeutic interventions of CBT, IPT, and SSRIs in treating childhood depression.18 When children and adolescents have been prescribed an SSRI as part of their treatment, the NP must closely monitor adverse effects of the medication, as well as potential drug reactions and interactions including those with illicit substances.
Depression criteria and symptomatology21
* Weight changes
* Insomnia or hypersomnia
* Psychomotor agitation or retardation
* Fatigue or loss of energy
* Feelings of worthlessness or excessive guilt
* Inability to concentrate
* Thoughts of death, suicide ideation, or suicide attempts
Key points of the mental status exam24
* Appearance (hygiene, facial expressions)
* Motor activity
* Affect and mood
* Presence of psychotic symptoms
* Suicidal or homicidal ideation or plan
* Development and cognitive status
* Thought content (self-image, future goals, preoccupations)
* Insight into problem
* Judgment relative to age
* Elevated, expansive, or irritable mood lasting at least 1 week
* Inflated self-esteem or grandiosity
* Decreased need for sleep (such as feeling rested after only 3 hours of sleep)
* Being more talkative than usual or pressure to keep talking
* Flight of ideas or subjective experience that thoughts are racing
* Distractibility (such as attention easily being drawn to unimportant or irrelevant external stimuli)
* Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
* Excessive involvement in pleasurable activities that have a high potential for painful consequences (such as engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
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