> Table of Contents > Depression, Adolescent
Depression, Adolescent
Nanette Lacuesta, MS, MD
Joseph Gladwell, MD
image BASICS
DESCRIPTION
  • DSM-5 depressive disorders include disruptive mood dysregulations disorder (DMDD), major depressive disorder (MDD), dysthymia, premenstrual dysphoric disorder, substance-/medication-induced depressive disorder, and other nonspecific depression. This chapter focuses on MDD.
  • MDD is a primary mood disorder characterized by sadness and/or irritable mood with impairment of functioning; abnormal psychological development; and a loss of self-worth, energy, and interest in typically pleasurable activities.
  • DMDD is characterized by a chronic, severe persistent irritability with frequent temper outbursts in response to frustration.
  • Dysthymic disorder is differentiated from major depression by less intense symptoms that are more persistent, lasting at least 1 year.
  • Adolescents with depression are likely to suffer broad functional impairment across social, academic, family, and occupational domains, along with a high incidence of relapse and a high risk for substance abuse and other psychiatric comorbidity.
EPIDEMIOLOGY
Incidence
During adolescence, the cumulative probability of depression ranges from 5% to 20% (1,2).
Prevalence
  • MDD: 6-12% of adolescents; twice as common in females (1)
  • DMDD: 2-5%; more prominent in males (3)
ETIOLOGY AND PATHOPHYSIOLOGY
  • Unclear; low levels of neurotransmitters (serotonin, norepinephrine) may produce symptoms; decreased functioning of the dopamine system also contributes.
  • External factors may affect neurotransmitters independently.
Genetics
  • Offspring of parents with depression have three to four times increased rates of depression compared with offspring of parents without mood disorder (2).
  • Family studies indicate that anxiety in childhood tends to precede adolescent depression (2).
RISK FACTORS
  • Increased three to six times if first-degree relative has a major affective disorder; three to four times in offspring of parents with depression
  • Prior depressive episodes
  • History of low self-esteem, anxiety disorders, attention deficit hyperactivity disorder (ADHD), and/or learning disabilities
  • Hormonal changes during puberty
  • Female gender
  • Low socioeconomic status
  • General stressors: adverse life events, difficulties with peers, loss of a loved one, academic difficulties, abuse, chronic illness, and tobacco abuse
GENERAL PREVENTION
Insufficient evidence for universal depression prevention programs (psychological and social) (4)[B]
  • Some evidence indicates that child and adolescent mental health can be improved by successfully treating maternal depression (2,4)[A].
  • Agency for Healthcare Research and Quality (AHRQ) recommends the screening of adolescents (12 to 18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up (5)[C].
COMMONLY ASSOCIATED CONDITIONS
  • 2/3 of adolescents with depression have at least one comorbid psychiatric disorder.
  • 20% meet the criteria for generalized anxiety disorder.
  • Also associated with behavioral disorders, substance abuse, eating disorders
image DIAGNOSIS
PHYSICAL EXAM
  • Psychomotor retardation/agitation may be present.
  • Clinicians should carefully assess patients for signs of self-injury (wrist lacerations) or abuse.
DIFFERENTIAL DIAGNOSIS
  • Normal bereavement
  • Substance-induced mood disorder
  • Bipolar disorder
  • Mood disorder secondary to a medical condition (thyroid, anemia, vitamin deficiency, diabetes)
  • Organic CNS diseases
  • Malignancy
  • Infectious mononucleosis or other viral diseases
  • ADHD, posttraumatic stress disorder (PTSD), eating disorders, and anxiety disorders
  • Sleep disorder
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
May be used to rule out other diagnoses (i.e., CBC, TSH, glucose, mono spot, and urine drug)
Follow-Up Tests & Special Considerations
None with sufficient sensitivity/specificity for diagnosis
Diagnostic Procedures/Other
  • Depression is primarily diagnosed after a formal interview, with supporting information from caregivers and teachers.
  • Standardized tests are useful as screening tools and to monitor response to treatment but should not be used as the sole basis for diagnosis:
    • Beck Depression Inventory (BDI): ages 12 to 18 years (2)[A]
    • Child Depression Inventory (CDI): ages 7 to 17 years
    • Reynolds Adolescent Depression Scale (RADS): teenagers in grades 7 to 12
    • Mood and Feelings Questionnaire (MFQ) (6)[A]
    • Patient Health Questionnaire-9 (PHQ-9): ages 13 to 17 years with ideal cut point of 11 or higher (instead of 10 used for adults) (7)[B]
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents in a primary care setting (8)[C].
image TREATMENT
GENERAL MEASURES
  • Active support and monitoring with short validated scales should be used in mild cases for 6 to 8 weeks.
  • Psychotherapy and/or medication should be considered if active support and monitoring do to improve symptoms (9)[A].
  • Treatment should include psychoeducation, supportive management, and family and school involvement (10)[C].
  • Initial management should include treatment planning and ensuring that the patient and family is comfortable with the plan (11)[C].
  • A Cochrane review showed that there was no significant difference between remission rates for adolescents treated with cognitive behavioral therapy (CBT) versus medication or combination therapy immediately postintervention (12)[A].
  • A multitreatment meta-analysis showed that combined fluoxetine/CBT had higher efficacy than monotherapies, but other SSRIs such as sertraline and escitalopram were better tolerated (9)[A].
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MEDICATION
First Line
  • Fluoxetine: for depression in age >8 years. Starting dose of 10 mg/day; effective dose of 10 to 60 mg/day The most studied SSRI and with the most favorable effectiveness and safety data has the longest half-life of the SSRIs and is not generally associated with withdrawal symptoms between doses or upon discontinuation (13)[A].
  • Escitalopram: for depression in age >12 years. Starting dose of 5 mg/day; effective dose of 10 to 20 mg/day (13)[A]
  • Citalopram: for depression in age >12 years. Starting dose of 10 mg/day; effective dose of 10 to 40 mg/day (13)[A]
  • Sertraline: for depression in age >12 years. Starting dose of 25 mg/day; effective dose of 50 to 200 mg/day (13)[A]
  • Can titrate dose every 1 to 2 weeks if no significant adverse effects emerge (headaches, GI upset, insomnia, agitation, behavior activation, suicidal thoughts) (13)[A]
  • SSRI black box warning to monitor for worsening condition, behavior changes, and suicidal thoughts (13)[A]
  • Antidepressant treatment should be continued for 6 to 12 months after the resolution of symptoms at the same dosage (10)[C].
  • Given their rates of increased drug metabolism, adolescents may be at higher risk for withdrawal symptoms from SSRIs than adults; if these are present, twice-daily dosing may be considered (9)[A].
  • All other SSRIs except fluoxetine should be slowly tapered when discontinued (9)[A].
Pediatric Considerations
  • Tricyclic antidepressants (TCAs) have not been proven to be effective in adolescents and should not be used (9)[A].
  • Paroxetine (SSRI): Avoid use due to short half-life, associated withdrawal symptoms, and higher association with suicidal ideation.
ISSUES FOR REFERRAL
  • Collaborative care interventions between mental health and primary care have a greater improvement in depressive symptoms after 12 months (14)[B].
  • Primary care providers should provide initial treatment of pediatric depression. Refer to a child psychiatrist for severe, recurrent, or treatment-resistant depression or if the patient has comorbidities (13)[A].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Physical exercise and light therapy may have a mild to moderate effect (15)[B].
  • St. John's wort, acupuncture, S-adenosylmethionine, and 5-hydroxytryptophan have not been shown to have an effect or have inadequate studies to support use in adolescent depression (15)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
If severely depressed, psychotic, suicidal, or homicidal, one-on-one supervision may be needed.
image ONGOING CARE
Patient Monitoring
  • Systematic and regular tracking of goals and outcomes from treatment should be performed, including assessment of depressive symptoms and functioning in home, school, and peer settings (13)[A].
  • Diagnosis and initial treatment should be reassessed if no improvement is noted after 6 to 8 weeks of treatment (13)[A].
  • The goal of treatment should be no symptoms or a significant reduction of depressive symptoms for 2 weeks (10)[C].
  • Educate patients and family members about the causes, symptoms, course and treatments of depression, risks of treatments, and risk of no treatment.
PROGNOSIS
  • 60-90% of episodes remit within 1 year.
  • 50-70% of remissions develop subsequent depressive episodes within 5 years.
  • Depression in adolescence predicts mental health disorders in adult life, psychosocial difficulties, and ill health (2)[A].
  • Baseline symptom severity and comorbid anxiety may impact treatment response (16)[A].
  • Parental depression at baseline significantly affects intervention effects (4)[A].
REFERENCES
1. Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am Fam Physician. 2012;86(5):442-448.
2. Thapar A, Collishaw S, Pine DS, et al. Depression in adolescence. Lancet. 2012;379(9820):1056-1067.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
4. Beardslee WR, Brent DA, Weersing VR, et al. Prevention of depression in at-risk adolescents: longer-term effects. JAMA Psychiatry. 2013;70(11):1161-1170.
5. U.S. Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics. 2009;123(4):1223-1228.
6. Thapar A, Collishaw S, Potter R, et al. Managing and preventing depression in adolescents. BMJ. 2010;340:c209.
7. Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;(3):CD004691.
8. Richardson LP, McCAuley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117-1123.
9. Ma D, Zhang Z, Zhang X, et al. Comparative efficacy, acceptability, and safety of medicinal, cognitive-behavioral therapy, and placebo treatments for acute major depressive disorder in children and adolescents: a multiple-treatments meta-analysis. Curr Med Res Opin. 2014;30(6):971-995.
10. Birmaher B, Brent D. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526.
11. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120(5):e1313-e1326.
12. Cox GR, Callahan P, Churchill R, et al. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev. 2014;(11):CD008324.
13. Cheung AH, Kozloff N, Sacks D. Pediatric depression: an evidence-based update on treatment interventions. Curr Psychiatry Rep. 2013;15(8):381.
14. Reeves GM, Riddle MA. A practical and effective primary care intervention for treating adolescent depression. JAMA. 2014;312(8):797-798.
15. Popper CW. Mood disorders in youth: exercise, light therapy, and pharmacologic complementary and integrative approaches. Child Adolesc Psychiatr Clin N Am. 2013;22(3):403-441.
16. Nilsen TS, Eisemann M, Kvernmo S. Predictors and moderators of outcome in child and adolescent anxiety and depression: a systematic review of psychological treatment studies. Eur Child Adolesc Psychiatry. 2013;22(2):69-87.
Additional Reading
&NA;
  • Emslie GJ, Mayes T, Porta G, et al. Treatment of resistant depression in adolescents (TORDIA): week 24 outcomes. Am J Psychiatry. 2010;167(7):782-791.
  • LeFevre ML. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719-726.
Codes
&NA;
ICD10
  • F32.9 Major depressive disorder, single episode, unspecified
  • F33.9 Major depressive disorder, recurrent, unspecified
  • F33.8 Other recurrent depressive disorders
Clinical Pearls
&NA;
  • Adolescent depression is underdiagnosed and often presents with irritability and anhedonia.
  • Fluoxetine is the most studied FDA approved for treatment of adolescent depression.
  • Escitalopram, citalopram, and sertraline are also FDA-approved antidepressants.
  • CBT combined with fluoxetine is efficacious for adolescents with major depression.
  • Paroxetine and TCAs should not be used to treat adolescent depression.
  • Referral to a child psychiatrist is appropriate for complex cases or treatment-resistant depression.
  • Monitor all adolescents with depression for suicidality, especially during the 1st month of treatment with an antidepressant.