Persons with this condition have one major depressive episode or a history of such a disorder and one episode of hypomania. This hypomanic episode is similar to a manic episode but differs in that a hypomanic episode only lasts a few days and does not cause a severe disruption in social, family, educational, and work func- tioning. The child or adolescent has never suffered from a manic episode or one that involved both depressed and manic symptoms. These mood episodes cannot be better explained by schizoaffective disorder, delusional disorder, schizophrenia, or psychotic disorder. Overall, these symptoms cause the children and adolescents marked distress and substantial impairment in functional status.
Depressive Disorder Not Otherwise Specified (NOS)
A large percentage of adolescents who suffer depressive symptoms and significant distress or disruption in functioning do not meet the criteria for a MDD (Sihvola et al.,2007; Gonzalez-Tejera et al.,2005). Many of these individuals may fulfill the criteria for depressive disorder not otherwise specified (DDNOS). Minor depres- sion (mDEP) is one type of DDNOS. Adolescents who suffer from mDEP may be underdiagnosed and untreated (Sihvola et al.,2007). They have not been consid- ered serious enough to warrant treatment and the risk factors for this disorder have not been studied extensively. In mDEP, the individual does not experience the five symptoms required for a MDD (Gonzalez-Tejera et al.,2005).
Minor depression in adolescence is poorly understood due to the scarcity of research in this area. Nevertheless, some studies reveal the traumatic impact of this condition. Based on a sample of 909 girls and 945 boys (mean age of 14 years), Sihvola et al. (2007) discovered that mDEP was linked to suicidal thoughts, plans and attempts, recurrences, and a greater number of comorbid conditions. Fourteen percent of adolescents younger than age 15 years had depressive symptoms with severe potential. However, a majority of them did not fulfill the criteria for MDD.
Only 1.7% of the adolescents had been in any type of psychiatric therapy. Forty per- cent of the depressed adolescents who had made a suicide attempt had no contact with the mental health system.
In a study of mDEP among Puerto Rican adolescents, aged 11–17, Gonzalez- Tejera et al. (2005) reported that youth with minor depression suffered substantial impairment, and compared to those with a MDD, they used more mental health services. Both adolescents with minor depression and MDD had similar comorbidi- ties and correlates.
Youth who suffer minor depression may be at elevated risk for a major depressive disorder and associated impairment. Using data from the Pittsburgh Girls Study,
Keenan et al. (2008) showed that girls who did not have a MDD at age 9 years had an elevated risk of developing a MDD and suffering related impairment at age 10 or 11 years, as the number of their depressive symptoms increased. The authors noted that these results highlight the stability in minor depression among pre-adolescent girls. They recommend secondary prevention of depression in girls by treating minor depression as it emerges.
Assessment
The diagnostic criteria for depression in children and adolescents are basically the same as those for adults (Bhatia and Bhatia,2007). However, the expression of symptoms of depressive disorders varies by age (Son and Kirchner,2000). Extensive research has evaluated school-aged children and adolescents; however, investigators know less about the extent to which preschoolers develop depression (Luby et al., 2009; Curtis and Luby,2008).
Using a sample of 305 preschoolers, aged 3–6 years, Luby et al. (2009) showed that functional impairment was linked to depression in this sample. These functional impairments were observed in different domains and contexts. Guilt-related symp- toms and severe fatigue were very specific for depression in these preschoolers.
However, the investigators did not find that depression was related to develop- mental delays in preschoolers. The authors suggest that there is a window of opportunity to intervene early in preschoolers since depressed preschoolers were not developmentally delayed.
In another study of preschoolers, Curtis and Luby (2008) reported that chronic medical conditions were linked to the early onset of depressive symptoms and impaired social functioning in several areas. Chronic health problems were asso- ciated with more severe depression, an increased frequency of asocial behav- ior, impaired behaviors toward others, and poor cooperation with daycare roles.
Preschoolers with at least one chronic health problem were more likely to suffer more frequent peer rejection and bullying relative to peers who do not have chronic health problems.
For the most part, infants and preschoolers are unable to use language to express sadness (Son and Kirchner,2000). As a result, clinicians have to infer symptoms of sadness from actual behavior, such as evidence of apathy, social withdrawal, a failure to meet developmental milestones or a regression of milestones, and a failure to thrive that cannot be explained by medical causes (Jellinek and Synder,1998;
Wolraich et al.,1996). Providers need to rely on different data sources to help make the diagnosis, such as parental history, interactions between parent and child, and play interviews (Lewis,1996).
As children reach school age, they develop the ability to internalize various stressors, such as family conflict and difficulties in school, and as a consequence develop problems, such as low self-esteem and feeling guilty (Son and Kirchner, 2000). School-aged children often express these problems by having somatic com- plaints such as stomachaches and headaches. They may also exhibit their problems
Assessment 159 by experiencing school phobia, separation anxiety, and other types of anxiety- related conditions. Moreover, these children demonstrate their turmoil in the form of irritability, such as temper tantrums, and other behavioral difficulties.
Using longitudinal data on 232 nine-year-old girls from the Pittsburgh Girls Study, Keenan et al. (2008) discovered that early developing depressive symptoms in girls are stable. Moreover, they found that these early emerging symptoms of depres- sion predict depressive disorders and impairment in functioning. The investigators recommend interventions for girls who are suffering these emerging symptoms to achieve secondary prevention of depression in this vulnerable population.
Teachers should be consulted and involved in the assessment process because during school hours they spend a considerable amount of time with these children (Son and Kirchner,2000). Depressive symptoms may go undetected since depressed children may try to make up for their low self-esteem by performing well in school in order to please their teachers (Jellinek and Synder,1998).
During the storm and stress of adolescence, young people are especially vulnera- ble to feelings of depression (Son and Kirchner,2000). They can develop depressive symptoms as they have difficulties becoming independent and forming their self- identity. Compared to depressed school-aged children, depressed adolescents suffer more intense feelings of hopelessness. Moreover, they have greater capacity to kill themselves than younger children. Depressed adolescents show less interest in plea- surable activities, sleep excessively, experience more changes in their weight, and experience substance abuse compared to depressed school-aged children. Given the problems of adolescence, e.g., the tendency of adolescents to challenge authority, clinicians need to establish a trusting relationship with their adolescent patients and should inform them about when information will be divulged to parents or others (Lewis,1996).
Although differences have been identified between depressed school-aged chil- dren and depressed adolescents, both have similar symptoms with regard to major depressive disorder (Son and Kirchner, 2000). The frequency and severity of their symptoms, including depressed mood, feelings of guilt, irritability, and low self-esteem, overlap among both groups (Ryan et al.,1987).
Clinicians should consider the possibility that the child or adolescent has dys- thymic disorder, which has milder symptoms but lasts longer than major depressive disorder. The persistence of dysthymic disorder can impair the individuals’ acquisi- tion of social skills that can help them deal with these difficulties (Son and Kirchner, 2000).
MDD and dysthymic disorder can have substantial comorbidity, especially comorbid psychiatric conditions (Treatment for Adolescents with Depression Study (TADS), 2005; Son and Kirchner, 2000; Birmaher et al., 1998). Based on a study of 439 adolescents, in the 12–17 year age group, the researchers reported that the most prevalent comorbid conditions were generalized anxiety disorder (15.3%), attention-deficit hyperactivity disorder (13.7%), ODD (13.2%), social phobia (10.7%), and dysthymic disorder (10.5%).
Youth can also suffer so-called double depression when one condition becomes superimposed on the other. Young people with comorbid conditions have a more
negative prognosis because comorbidity is linked to increased duration and severity of MDD symptoms. Moreover, comorbid conditions increase the likelihood that a MDD will reoccur as well as suicidal risks (Jellinek and Synder,1998; Birmaher et al.,1996; Ryan et al.,1987; Kovacs et al.,1984).
Diagnosis
Most psychosocial conditions are missed by health-care providers (Son and Kirchner,2000). Some investigations have found that only one-third of parents who were worried about their children’s psychosocial functioning indicated that they were going to share their concerns with their pediatrician. Furthermore, only 40%
of the pediatricians responded when the parents actually did discuss their children’s psychosocial issues with their pediatrician. Research indicates that the pediatri- cian’s response rate was even lower if the parents had lower levels of educational attainment (Cassidy and Jellinek,1998; Jellinek et al.,1995).
The failure of health-care clinicians to diagnose and treat depression in children and adolescents is especially serious since effective assessment and treatment can reduce the substantial morbidity and mortality associated with these disorders (Son and Kirchner,2000). Screening measures, such as the Pediatric Symptom Checklist, should be used. The Pediatric Symptom Checklist is a 35-item instrument, which is completed by parents of children aged 6–12 years (Jellinek et al.,1995,1988).
This protocol has been found to have good specificity and sensitivity and is easy to administer. Therefore, the tool can help physicians improve their assessment of patients in busy health-care settings.
After a patient has been identified, the clinician should obtain a thorough psy- chosocial history to determine if the patient should receive treatment or a referral (Son and Kirchner, 2000; Hack and Jellinek, 1998). To diagnose depressive dis- orders, the provider must complete a complete medical and psychiatric assessment.
Clinicians should order laboratory studies based on the patient’s history and physical examination.
Clinicians should assess the possibility that various medical conditions are caus- ing depressed symptoms in children and adolescents (Son and Kirchner, 2000).
Infections, neurologic disorders, endocrine disorders, medications, and other con- ditions, such as substance abuse, electrolyte abnormality, hypokalemia, anemia, and Wilson’s disease, may cause depression. Laboratory studies include complete blood cell count with differential, determination of electrolytes, creatinine level, BUN, liver function studies, thyroid function tests, and electroencephalogram.
A psychiatric assessment involves taking a history that details the onset, dura- tion, frequency, intensity, and severity of symptoms (Son and Kirchner,2000). The provider also should consider if the patient’s symptoms occur in different settings such as home and school. Various medical and psychiatric conditions should be ruled out since depression is associated with chronic medical conditions in young people and many psychiatric comorbid disorders. In addition, the practitioner should take a developmental history, social history, and family history regarding psychiatric
Treatment 161 conditions. It is also essential that the clinician elicit possible stressors in the patient’s home, school, and community (Lewis,1996; Cassidy and Jellinek,1998).
The clinician should conduct a clinical interview that is tailored to the patient’s age and developmental stage (Son and Kirchner, 2000). For infants and tod- dlers, unstructured play interviews and observation of child–parent behaviors are recommended. For children of school age, play interviews along with open- ended questioning is suggested. For adolescents, in-depth interviews are suggested.
Neuropsychologic testing can help determine if the patient has neurologic or learning problems and developmental stage (Lewis,1996).
When the pediatrician perceives possible depression, referral to an appropriate mental health practitioner should be considered. However, many physicians treat mild to moderate depression in children and adolescents and do not feel the need to make a referral. In instances when counseling appears to be needed, or in more severe depressions when psychotropic medication appears to be needed, a referral may be necessary.
Treatment
The best treatment for depression in children and adolescents is multidisciplinary in nature and includes different forms of psychotherapy, psychosocial interven- tions, educating the patient and family, and using medications (Kapornai and Vetro, 2008; Mehler-Wex and Kolch,2008; Michael and Crowley,2002; Son and Kirchner, 2000).
The treatment of child and adolescent depression has been classified into three phases: acute, continuation, and maintenance (Emslie et al.,2005). In the acute phase, the young person responds to treatment and has a remission of symptoms.
Prevention of symptom relapse occurs in the continuation phase. In the mainte- nance phase, the young person does not develop new episodes or recurrences of depression.
Use of selective serotonin reuptake inhibitors (SSRIs) is thought to be the first- line therapy for the acute treatment of depression in children and adolescents (Emslie et al.,2005). Non-specific psychotherapy may be utilized as an adjunctive strategy in the management of depressive symptoms, but non-specific psychother- apy has not been shown to be as effective as medications or specific psychotherapies alone. By contrast, cognitive behavior therapy (CBT) and interpersonal therapy have been found to be effective in the treatment of early-onset depression. However, severe symptoms of depression, comorbid conditions, family conflict, and increased disability are obstacles to remission and promote non-compliance.
For children and adolescents with mild to moderate depression, psychotherapy can be an effective, initial treatment strategy (Son and Kirchner,2000). For chil- dren with more severe symptoms, psychotherapy should be used as an adjunct to medications (Birmaher et al., 1998). Practitioners should consider a range of psychotherapeutic approaches, including play therapy, supportive therapy, family therapy, and CBT. The choice of approaches depends on the patient’s cognitive
and emotional development. For depressed children of pre-school age, play ther- apy and parental education would be recommended. In contrast, older children and adolescents would benefit from psychodynamic therapy or CBT (Weller et al., 1996).
Most research suggests that CBT appears to be the psychotherapy modality of choice for the treatment of child and adolescent depression. CBT has been found to be useful for patients 10 years and older (Son and Kirchner,2000). This strategy helps patients change their negative views about themselves and the environment.
Reinecke et al. (1998), in their meta-analysis, found that for adolescents with depressed or dysphoric mood, CBT was effective on a short-term and long-term basis. CBT has been shown to be more useful than nondirective supportive therapy and systemic-behavioral family therapy because CBT seems to deal with the dis- torted cognitions that are prevalent in this age group (Brent et al.,1998). However, Kapornai and Vetro (2008) report that recent research on psychotherapies reveals a different picture regarding effectiveness.
Other reports reveal that different types of psychotherapy are effective in treat- ing moderate to severe depression in children and young adolescents. For example, Trowell et al. (2007) reported that both individual therapy and family therapy resolved depressive symptoms in patients aged 9–15 years.
For the treatment of dysthymic disorder, multiple interventions may be effective since this condition is frequently associated with different psychosocial problems.
The goals of treating dysthymic disorder are to eliminate the depressive symp- toms, reduce the risk of other mood disorders, and enhance the functional status (Nobile et al.,2003). Individual psychotherapy, family therapy, family education, and medication can be helpful. In children and adolescents with moderate to severe depression who have either dysthymic disorder or double depression, CBT and inter- personal therapy have been shown to be effective. SSRIs are the first-line medical treatment for children and adolescents with dysthymia because of their safety and ease of administration. However, it is essential for parents and other caregivers to receive psychoeducational interventions and psychosocial support during the acute treatment phase. These interventions and support will help the parents and care- givers cope with their child’s irritable mood and help ensure patient compliance.
Both acute and continuation treatment approaches should be emphasized.
For children and adolescents with bipolar disorder, research indicates that med- ication plays a primary role in treatment. However, adjunctive psychosocial treat- ment also plays an important role (West and Pavuluri,2009). Preliminary evidence suggests that multi-family psychoeducational groups and child- and family-centered CBT are effective for the treatment of bipolar disorder in school-aged children. For adolescents with bipolar disorder, interpersonal and social therapy produces positive outcomes.
The use of selective serotonin reuptake inhibitors (SSRIs) to treat depressive symptoms in children and adolescents can be effective (Brent et al.,2008; March et al.,2007). The side effects of SSRIs include mild gastrointestinal upset and sleepi- ness (Son and Kirchner,2000). However, the US Food and Drug Administration issued warnings that using antidepressants can result in a small but significant risk
Treatment 163 of suicidal ideation and suicide attempts among children and adolescents (Bridge et al.,2007). Once children are placed on an antidepressant, family members should watch them closely for any alterations in behavior, especially increased suicidal ideation (Brock et al.,2005). Any changes in behavior should be reported to the primary health-care provider immediately for assessment.
Based on a review of 27 trials of antidepressant treatment for pediatric patients with MDDs, obsessive–compulsive disorder (OCD), and non-OCD anxiety disor- ders, Bridge et al. (2007) showed that the benefits of antidepressants seem to be much greater than the risks of suicidal ideation or suicide attempts. However, the risk–benefit analysis depends on the indication for antidepressants, the patient’s age, the chronic nature of the disorder, and the experimental conditions of the different trials.
Reports on adults have not found differences in the risk of suicide for patients treated with antidepressants and those in the placebo group (Hjalmarsson et al., 2005; Hammad et al.,2006). In these trials, the few numbers of suicides and the subsequent lack of statistical power make it impossible to determine whether drug or placebo treatment increases the risk of suicide (Hammad et al.,2006).
Using results from the Treatment for Adolescents with Depression Study (TADS), Vitiello et al. (2009) analyzed suicidal events during a 36-week ran- domized, controlled clinical trial with 439 youths receiving medications and psychotherapy. Forty-four patients experienced at least one suicidal event (attempt or ideation) and no completed suicides occurred. Suicide attempts or ideation took place on average 0.4–31.1 weeks after initiating treatment. Patients who received medication did not differ between those who did receive medications with regard to the timing of these suicide events. The results indicated that the severity of baseline suicidal ideation and symptoms of depression increased the probability of suicidal ideation and attempts during treatment. Patients who suffered suicide events were more likely to have moderate illness before the event and showed only minimal improvement. The authors suggest that a majority of suicidal attempts and ideation took place because of chronic depressive symptoms and inadequate improvement rather than in response to medications.
Researchers have been investigating the effectiveness of SSRIs, alone or com- bined with CBT. Brent et al. (2008) noted that only approximately 60% of depressed adolescents will improve with an initial trial of a SSRI. They conducted a random- ized, controlled trial using 334 patients with major depressive disorder, aged 12–18, who had not responded to a 2-month initial treatment with an SSRI. The researchers showed that for these patients, combining CBT and changing to another antide- pressant produced greater improvements than just switching to another drug alone.
However, changing to another SSRI was just as effective as changing to venlafaxine and produced fewer side effects.
Based on data from TADS, a randomized, controlled trial in 13 academic and community settings, March et al. (2007) revealed that the SSRI, fluoxetine, alone or combined with CBT, accelerated improvements in adolescents with moderate to severe depression. The investigators also found that the safety of the drug was improved by adding CBT.