Mental Health: Depression

Column Author: Theodore Brisimitzakis, DO| Clinical Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

Column Editor:  Sara J Anderson, MD, MPH | Clinical Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

Depression and You:

According to the Centers for Disease Control and Prevention (CDC), 4% of children aged 3-17 have a current diagnosis of depression while 79% of these children obtained counseling or treatment. This article serves as a practical guide for depression diagnosis and treatment in the general practitioner’s office.

Depression:

The American Academy of Pediatrics recommends universal screening for depression in adolescents to provide early identification and intervention. There are several screening tools for assessing depression in children and adolescents. The two most widely used are the Patient Health Questionnaire 9 (PHQ-9) and the Columbia Depression Scale.

If there is a positive score and concern for depression, it is important to conduct a diagnostic interview to accurately assess the condition. The Diagnostic and Statistical Manual of Mental Disorders-5^th Edition (DSM-5) provides criteria for diagnosing depression and includes specific criteria for major depressive disorder and other depressive disorders. This resource can be helpful for further diagnostic classification. It is important to recognize that depression in youth can manifest differently. Common presentations include irritability instead of a depressed mood, changes in appetite or weight (including failure to gain weight as expected), sleep disturbances, and physical complaints like headaches or stomachaches. Additionally, children and adolescents may exhibit difficulty concentrating, fatigue, low energy, and social withdrawal. 

The first-line medication treatments of major depressive disorder include selective serotonin reuptake inhibitors (SSRIs). Several SSRI medications are indicated for children and adolescents. The most commonly prescribed are fluoxetine, escitalopram and sertraline. Only fluoxetine and escitalopram are approved by the Food and Drug Administration (FDA) for depression in children and adolescents, although age ranges are variable. Common side effects across all SSRIs include GI upset, headache and sleep disturbances. It is important to note that SSRIs may cause activation syndrome in children and adolescents, characterized by symptoms such as irritability, impulsivity and restlessness. This side effect is more common in younger patients and typically occurs within the first two to three weeks of treatment. All antidepressant medications prescribed for patients younger than 24 years of age carry the black box warning for increased risk of suicidal ideation.

If a child or adolescent being treated for depression has failed one SSRI at a therapeutic level, the next step is to trial a second SSRI. While not FDA approved for depression in children, sertraline and duloxetine (a serotonin-norepinephrine reuptake inhibitor) could be considered first-line options for treatment. The website Up to Date provides information regarding depression, medication side effects and dosing strategies. For families, parentsmedguide.org provides information of commonly prescribed psychiatric medications from the American Academy of Child and Adolescent Psychiatrists (AACAP).

References:

1. Data and statistics on children’s mental health. Centers for Disease Control and Prevention. August 19, 2024. https://www.cdc.gov/children-mental-health/data-research
2. Facts about suicide. Centers for Disease Control and Prevention. July 23, 2024. https://www.cdc.gov/suicide/facts/index.html
3. Costantini L, Pasquarella C, Odone A, et al. Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): a systematic review. J Affect Disord. 2021;279:473-483. PMID: 33126078. doi:10.1016/j.jad.2020.09.131
4. Hetrick SE, McKenzie JE, Bailey AP, et al. New generation antidepressants for depression in children and adolescents: a network meta-analysis. Cochrane Database Syst Rev. 202124;5(5):CD013674. PMID: 34029378. PMCID: PMC8143444. doi:10.1002/14651858.CD013674.pub2