Paediatrics: Depression

Depression

Loose usage of the words ‘depression’ and ‘depressed’ causes much con-fusion. They can refer to a mood, which may be appropriate, a symptom, or a mental disorder.

Prevalence

Approximately 10% of 10-yr-olds are reported by parents and teachers, and 20% of 14-yr-olds report themselves to be often miserable. However, the rate of diagnosable depressive disorder in a community sample of 11–16-yr-olds is closer to 3%. The discrepancy is due to those who suffer low moods, but do not meet full diagnostic criteria.

Aetiology

Genes increase both the risk of developing depression and of experiencing negative life events. Post-pubertally females are twice as likely as males to become depressed and possible links to oestrogen levels, either in utero or post-puberty, have been suggested. Females may also be more influenced by lack of positive relationships, close friendships, or a supportive peer network. Environmental factors include; early adversity and attachment difficulties, negative or traumatic life events or abuse, death of a parent, drug and alcohol abuse, and bullying. Psychosocial factors include; social isolation and negative interpersonal relationships, poor academic achieve-ment, unstable family environment, parental drug and alcohol abuse.

Clinical features

Diagnosis of depressive disorder requires that mood is persistently lowered and accompanied by a loss of interest and enjoyment and/or increased fatigability for more than 2wks with a significant effect on func-tioning. There should also be at least two of the following symptoms;

·  Reduced concentration and attention.

·  Reduced self-esteem and self-confidence.

·  Ideas of guilt and unworthiness.

·  Bleak and pessimistic views of the future.

·  Ideas or acts of self-harm.

·  Diminished appetite.

• Disturbed sleep.

Depressive disorders are frequently recurrent so it is always important to ask about past episodes.

Dysthymia is a chronic enduring depressed state lasting for over a year, but without the intensity of a depressive episode.

Amongst those referred to child psychiatric clinics, comorbidity is com-mon, e.g. conduct disorder, obsessive compulsive disorder.

Management¹

Initial assessment should identify:

·  Significant risk of self-harm or suicide.

·  Significant lack of self-care or neglect.

Symptoms of manic episode or psychotic disorder.

·Comorbid psychiatric disorder.

·Previous history of moderate or severe depressive episodes.

When these are present, referral to a specialist child and adolescent men-tal health service is appropriate

First line treatment for mild depressive disorder with symptom duration less than 4wks

Supportive therapy and psychoeducation about depressive disorders are effective first line interventions in 30% of children and adolescents with recent onset of mild to moderate depressive symptoms. Advice should be given on sleep hygiene, nutrition, activity, and exercise. If there is no response to supportive management after 2–3mths, young people should be referred to Tier 2/3 CAMHS services for more intensive psychological therapy.

Treatment for moderate to severe depressive disorders

Psychological therapies are recommended as first line treatments for treating child and adolescent depressive disorders. Recommended prac-tice is that a block of psychological therapy should be undertaken prior to consideration of antidepressant medication. Supported approaches are cognitive behavioural therapy (CBT) and interpersonal therapy. Brief fam-ily therapy may be effective in some cases.

Response to treatment should be reviewed after 12wks

If there is a good response to treatment the course of therapy should be completed and follow up should be provided for 12mths after remission of symptoms (or 2yrs if the patient has had one or more previous episode of depression).

Where there is a poor response to treatment after 12wks the assess-ment, formulation, and treatment plan should be reviewed and comorbid diagnoses considered and any significant environmental factors investi-gated. If a diagnosis of depression remains, consider alternative psycho-logical therapy and/or antidepressant medication. The most commonly used medications are the selective serotonin re-uptake inhibitor antide-pressants. Recently there has been concern about side-effects (including increased suicide)  as well as efficacy. In the UK fluoxetine is the only medication that is currently recommended for use as an antidepressant in children. Tricyclics appear ineffective and should not be used.

Prognosis

Whilst recovery from a depressive disorder is likely, this may take months or in some cases years. Prognosis is worsened by increasing severity of disorder and by the presence of comorbid oppositional defiant disorder. Even in those who have made a good recovery, further depressive epi-sodes are not uncommon. Prolonged follow-up is, therefore, wise.