Get More Help in UtahDepression
Overview
Criteria for the diagnosis of major depression outlined in the DSM-5 [American: 2013] require symptoms that include 5 or more of the following: depressed mood, loss of interest or pleasure, sleep disturbance, appetite or weight disturbance, low energy, psychomotor disturbance, poor concentration, guilt or shame, and suicidal thoughts or behavior.
Depressive disorders are characterized by sad, empty, or irritable mood and accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function The various disorders differ primarily by timing, duration, and etiology. Depressive disorders are classified as MDD, disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, and other specified or unspecified depressive disorders. [American: 2013] This module will focus on MDD in children.
Other Names & Coding
F32.x, Major depressive disorder, single episode
F33.xx, Major depressive disorder, recurrent episode
F32.8, Other specified depressive disorder
F32.9, Unspecified depressive disorder
F34.1, Persistent depressive disorder (formerly dysthymia)
F34.8, Disruptive mood dysregulation disorder
F43.21, Adjustment disorder with depressed mood
F43.23, Adjustment disorder with mixed anxious and depressed mood
N94.3, Premenstrual dysphoric disorder
Prevalence
Genetics
Prognosis
Practice Guidelines
Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment,
and Initial Management.
Pediatrics.
2018.
PubMed abstract
Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.
Pediatrics.
2018.
PubMed abstract
Roles of the Medical Home
Clinical Assessment
Overview
Pearls & Alerts for Assessment
SuicidalityAssessment for depression must ALWAYS include assessment of current and past suicidality. If a patient is expressing suicidal thoughts, measures must be taken immediately to ensure safety. Please see Suicidality.
Depression and anxietyThe incidence of depression in children and youth with anxiety is up to 4-fold that of other children. Anxiety generally precedes the onset of depression, so carefully assess youth with anxiety for symptoms of depression.
SIGECAPSThis is a mnemonic for the symptoms of depression (save for the first symptom of depressed mood):
- S – sleep
- I – interest
- G – guilt
- E – energy
- C – concentration
- A – appetite or weight
- P – psychomotor changes
- S - suicidality
When assessing youth with depressive symptoms, it is important to interview the patient apart from the parents or caregivers for at least a portion of the visit; often, it is uncomfortable for the patient to discuss the symptoms or related life stressors with caregivers there. That said, it is equally important to speak to parents about the symptoms, current level of functioning, and past history.
Sub-threshold symptomsYouth with sub-threshold depressive symptoms (symptoms inadequate in duration or number to qualify for a specific diagnosis) are at increased risk for developing MDD and should be carefully monitored and assessed for its development.
Screening
For the Condition
The United States Preventive Services Task Force (USPSTF) recommends universal screening for depression in adolescents 12-18 years old. [Siu: 2016] Insufficient evidence exists to recommend universal screening for children 11 years old and younger. [Siu: 2016]The following validated tools may be used for screening. They may also be used in at-risk populations, to follow and quantify changes in depression severity over time, and in response to treatment.
- Beck Depression Inventory-II - ages 13 and older (available for a fee)
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Patient Health Questionnaire Modified for Adolescents (PHQ-A) (
228 KB) - ages 11 to 17 (free)
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Center for Epidemiological Studies Depression Scale for Children (CES-DC) ( 37 KB) - ages 12 to 18 (free)
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Center for Epidemiologic Studies - Depression Scale (CES-D) ( 171 KB) - ages 14 and older (free)
Of Family Members
120 KB) is often used in pediatric settings. The Portal has more information at
Postpartum Depression Screening.
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. [Siu: 2016] Referral to parents’ primary care clinician for screening or using the Center for Epidemiological Studies Depression Scale for Children (CES-DC) (
37 KB) in the pediatric setting may be appropriate.
Diagnostic Criteria
Depressive disorders in children and adolescents:
- Major depressive disorder (MDD) consists of 1 or more major depressive episodes (2 weeks or more of the symptoms described above). If mania or hypomania is present or has been present in the past, MDD cannot be diagnosed (thus, bipolar disorder excludes MDD).
- Persistent depressive disorder consists of depressed mood on most days for at least 1 year in children (2 years in adults). Persistent depressive disorder may be less severe than MDD in overall number of symptoms but, due to its chronicity, it can result in greater dysfunction in social and school/occupational areas.
- Premenstrual dysphoric disorder (PMDD) consists of symptoms presenting in the week before the onset of menses, including 1 or more of the following: depressed mood, anxiety, irritability, or mood swings combined with 1 or more of the following (for a total of 5 symptoms): loss of interest, poor concentration, low energy, appetite change, sleep disturbance, feeling overwhelmed, or physical symptoms.
- Disruptive mood dysregulation disorder (DMDD) is a new diagnosis meant to address the population of youth experiencing severe, chronic, non-episodic irritability with outbursts. It consists of severe, frequent (>3 times weekly), recurrent outbursts, inconsistent with developmental level and with persistent irritable or angry mood between outbursts over at least 12 months. If mania or hypomania has been present in the past, DMDD cannot be diagnosed (bipolar disorder excludes DMDD).
- Other specified depressive disorder, or unspecified depressive disorder may be diagnosed in situations when a patient has depressed mood but does not meet full symptom or duration criteria for MDD or persistent depressive disorder.
Bipolar depression is characterized by the presence of all of the symptom criteria for MDD and a history of mania or hypomania. Bipolar disorder often presents with symptoms of depression and is important to consider when evaluating a patient for a suspected depressive disorder. Many aspects of diagnosis and treatment of bipolar disorder are distinct from those of other depressive disorders.
Differential Diagnosis
Bipolar disorder may present with depressive symptoms. ALL of the symptoms of depression can be present in patients with bipolar disorder, in which patients alternate between depression and elevated mood states known as mania or hypomania. Diagnostic criteria for bipolar disorder in adults are well established, but there is controversy over their application in children and adolescents. Many aspects of treatment of bipolar disorder are distinct from those of other depressive disorders. Referral to a child and adolescent psychiatrist for diagnostic confirmation is appropriate.
Anxiety disorders may present with low self-esteem, worthlessness, apparent lack of motivation (often anxiety-based avoidance rather than true low motivation), sleep disturbance (insomnia is common as the patient lies awake worrying), eating problems (decreased appetite or eating rituals), and/or poor concentration. Eliciting specific mood symptoms (sadness, irritability) is important in differentiating these diagnoses. See Anxiety Disorders for assessment information.
Disruptive behavior disorders/ADHD may present with poor concentration, low self-esteem, and feelings of worthlessness due to social and academic difficulties.
Anorexia nervosa often presents with depressed or irritable mood, low motivation, and low energy, in addition to decreased food intake and weight loss.
Adjustment disorder with depressed mood consists of depressed mood and impaired function within 3 months of a clearly defined stressful life event. To be diagnosed with an adjustment disorder, the patient cannot meet full criteria for a major depressive episode.
Comorbid & Secondary Conditions
History & Examination
Current & Past Medical History
The history should address symptoms of depression that overlap with those of medical illness (e.g., insomnia, hypersomnia, low energy, appetite changes, and weight changes) and symptoms that might indicate an underlying medical cause for depression.An up-to-date history of medication use and current medications, including herbal medications (particularly St. John's Wort), dietary supplements, and OTC medications, is important, especially if medication therapy for depression is a consideration.
Interim History: Asking about depressive symptoms is the first step in ongoing assessment. A stepwise approach may help save time:
- Has the patient felt depressed, hopeless, or sad often over the past month, or has she/he felt less interest in or enjoyment of usual activities often over the past month. Depression and diminished interest (aka anhedonia) are cardinal symptoms of depression – one or the other must be present for diagnosis.
- Positive replies should prompt further questioning. The
combination of either depressed mood or diminished interest in usual
activities, along with 4 of the following symptoms fulfills criteria for
major depression:
- Changes in sleep
- Feelings of guilt or worthlessness
- Low energy
- Poor concentration
- Appetite or weight change
- Psychomotor slowing or agitation
- Suicidal thoughts or gestures
- See the above Pearl, SIGECAPS mnemonic for depressive symptoms. Gather information from both the child/adolescent and a guardian. Most child/adolescent mental health professionals agree that adding together symptoms from these separate reports is sufficient for diagnosis of depression. Symptoms must cause significant distress or dysfunction to meet criteria – ask about the impact on school, home, and social areas/activities. Because children may not report symptoms clearly, assessment of changes in behavior or function may provide the best clues.
Family History
Pregnancy/Perinatal History
There is growing interest in the relationship of perinatal factors, such as low birth weight, with depression in later life but conclusive data is lacking.Developmental & Educational Progress
Children and adolescents with developmental delays can also develop depression. The term "dual diagnosis" refers to the combination of intellectual disability and a psychiatric disorder in the same patient.
Social & Family Functioning
Clinically significant distress or impairment in social, occupational, or other important areas of functioning is one of the criteria for diagnosis of a major depressive episode. It is common for children and adolescents with depression to be more withdrawn from family or friends, more irritable, or less interested in normal activities.Physical Exam
General
A normal physical exam can help to rule out medical illness as a cause for depressive symptoms. Examination is also helpful to address the multiple physical complaints (e.g., abdominal pain) that may accompany depression. If a patient presents with concerns of depression, has had a recent physical exam (within the past 6-12 months), and has no new physical complaints or illnesses upon a review of systems, the physical exam may be deferred at the clinician's discretion to allow more time for interviewing.Testing
Laboratory Testing
Tests to consider in evaluation for a depressive disorder include TSH to screen for hypothyroidism and urine drug screen to screen for substance use, either of which may complicate or cause depression. A urine pregnancy test should be considered in females to allow for consideration of pregnancy in treatment decisions.Imaging
Routine use of imaging or EEG in the clinical evaluation of depressive disorders is not recommended. [Luby: 2016]Genetic Testing
Specialty Collaborations & Other Services
Psychiatry/Medication Management (see UT providers [56])
May aid in diagnosing depression and related conditions. Due to chronic shortages in the United States, they often see only those patients with the most severe mental illnesses or those with complicating biological, psychological, or social factors. Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features. See also AACAP Guidelines: When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist.
General Counseling Services (see UT providers [372])
This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.
Treatment & Management
Overview
Pearls & Alerts for Treatment & Management
Dose and duration of treatmentTo achieve full effect, 4 -6 weeks of an adequate dose with adequate adherence is required. This applies to ongoing treatment and management when the clinician should monitor and ensure these factors. When obtaining a report of prior treatment “failures,” assess whether adequate duration, dosage, and adherence were achieved.
Monitoring treatment efficacyMost of the screening tools listed in this module can also be used to monitor treatment efficacy.
Suicide riskAn independent review of available data by the American Medical Association indicated that “a causal role for antidepressants in increasing suicides in children and adolescents has not been established. ...Concerns that antidepressants potentiate suicidal or self-injurious behavior need to be balanced by the clear risk of suicide in children and adolescents with untreated depression.” [Jane: 2016] Another analysis of all available antidepressant RCTS in youth suggests that antidepressants have benefits that may outweigh these risks. [Bridge: 2007] There is also data demonstrating a correlation between higher rates of SSRI prescriptions and reduction in child and adolescent suicide rates. [Gibbons: 2006]
How should common problems be managed differently in children with Depression ?
Over the Counter Medications
Prescription Medications
Common medications and classes of medications may cause mood changes and therefore need to be monitored closely. Check for interactions.Systems
Mental Health/Behavior
Antidepressant medications include selective serotonin re-uptake inhibitors (SSRI), such as fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and vilazodone, and non-SSRI antidepressants, such as tricyclic antidepressants (TCA), bupropion, venlafaxine, desvenlafaxine, mirtazapine, duloxetine, levomilnacipran, and vortioxetine. Only fluoxetine and escitalopram are FDA approved for use under 18 years of age; use of all other antidepressants is considered “off label” for MDD in children and adolescents.
For details on use of medications to treat depression, as well as a discussion of antidepressants and suicidal adverse events, see Pharmacy& Medications below.
The other major treatment modality is psychotherapy, which refers to any psychology-based treatment directed by a trained mental health professional and delivered by means of communication or behavioral techniques. Psychotherapy is often referred to as ”counseling“ or “talk therapy.” Several types of psychotherapy exist but the only two with significant research evidence for efficacy in the treatment of depressive disorders in children and adolescents are cognitive behavior therapy (CBT) and interpersonal therapy (IPT).
Specialty Collaborations & Other Services
Psychiatry/Medication Management (see UT providers [56])
Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features. Due to chronic shortages in the US, psychiatrists often only see those patients with severe mental illness or complicating biological, psychological, or social factors. Consider referral for depression for patients who:
- Have no improvement after 6-8 weeks of medications or therapy
- Require more than 2 psychotropic medications to control symptoms
- Require psychiatric hospitalization
- Have parents with significant emotional impairment or substance use issues
- Have complex psychosocial issues (e.g., history of abuse/neglect, legal problems, poor parental support/supervision, family conflict)
- Have a family history suggesting adverse reactions to therapy (e.g., planned antidepressant therapy in a patient with family history of bipolar disorder)
- Are young (≤6 years old)
- Have chronic medical illness
General Counseling Services (see UT providers [372])
This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.
Pharmacy & Medications
General considerations for treatment with any antidepressant include: [Boylan: 2007]
- Start at low doses and titrate up over several days as tolerated.
- Patients should have frequent follow-up, preferably weekly until dose is stable and medication is tolerated.
- A trial at an adequate dose should go on 2-4 weeks before any further dose increase because it may take that long to see any benefit. If there is no beneficial effect after 2-4 weeks, dose may be increased.
- Antidepressants work best when taken daily at the same time.
- Most antidepressants with once-a-day dosing can be taken in the morning or evening based upon patient preference and observed side effects.
- Total trial time should be at least 6-8 weeks. A medication trial should not be considered a failure until the maximum tolerated dose has been used for this long without improvement.
- Family history of response to a particular medication may be used as an approximate guide for medication selection.
- The FDA approval of fluoxetine and escitalopram may make those medications appealing choices for clinicians; however, clinical judgment may lead to the use of other medications.
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the best-studied antidepressant medications for children and adolescents. They also have significant benefit for anxiety disorders including generalized anxiety disorder, panic disorder, and OCD. The effects of SSRIs on anxiety reduction are important given that anxiety disorders are commonly comorbid with depression.
SSRI side effects are usually mild and often transient. Common side effects include headaches, GI upset, somnolence, agitation, and sexual side effects (e.g., decreased libido, anorgasmia).
In both adults and children, SSRIs confer a small risk of serotonin syndrome, which is an adverse reaction and a medical emergency. Symptoms of serotonin syndrome include fever, confusion, and tremor/rigidity. Risk is increased by certain medication interactions. The most significant and dangerous medication interaction for SSRIs is with MAOIs (monoamine oxidase inhibitors – another type of antidepressant which is infrequently used in children). All patients should be questioned about other medications they are taking, including herbal and over-the-counter medications. If serotonin syndrome is suspected, SSRI should be immediately discontinued, and the patient should be referred to an emergency room for hospital admission. Combining SSRIs with any antidepressant including, but not limited to SNRIs, TCAs, and even other SSRIs, increases the risk for serotonin syndrome.
Treatment is supportive:
-
Fluoxetine has the most positive data from controlled trials in children and adolescents with 3 trials demonstrating significant difference
from placebo. [March: 2004]
[Emslie: 1997]
[Emslie: 2002] It has a longer half-life than most other SSRIs (1-4 days) and an active metabolite, norfluoxetine, which has an even longer
half-life (7-15 days). This can be a useful pharmacokinetic feature since it is somewhat more forgiving than other SSRIs when
doses are missed. However, if a patient has a negative reaction to fluoxetine, the long half-life can extend the duration
of the adverse reaction.
- FDA approved for use in children 8 years and older with MDD and those 7 years and older with obsessive-compulsive disorder
- Available as brand name (e.g., Prozac) and generic in several formulations, including 10 mg, 20 mg, 40 mg, and 60 mg tablets; 10 mg, 20 mg, and 40 mg capsules; 90 mg delayed release (weekly) capsules; 20 mg/5 ml solution
- Starting dose for adolescents: 10 to 20mg once daily, initial target dose 20mg once daily, dose range 10mg-60mg once daily
-
Sertraline has 1 positive trial (2 studies, which were combined by study design); however, the significance of the trial results was
lessened by a very high placebo response rate (53%). [Wagner: 2003] High placebo response rates are characteristic of all existing trials of antidepressants in children and adolescents.
- FDA approved for use in children 6 years and older with MDD
- Available as brand name (e.g., Zoloft) and generic in several formulations, including 25 mg, 50 mg, 100 mg tablets and 20 mg/ml oral concentrate
- Starting dose for adolescents: 12.5mg to 25mg once daily, initial target dose 50mg once daily, dose range 25mg to 200mg once daily
-
Paroxetine has 1 trial with mixed results [Keller: 2001] and 1 negative trial (unpublished, see [Cheung: 2005]), so the evidence for efficacy is equivocal. Paroxetine also appears to be less well tolerated in children and adolescents
in this author’s opinion and has significant discontinuation symptoms (possibly due to short half-life of 20 hours).
- Not FDA approved for use in children; other SSRIs may be a better choice for children and adolescents.
-
Citalopram has had 2 controlled trials. One had positive results [Wagner: 2004]; the other did not show a significant difference from placebo (unpublished). The non-significant study included inpatients
and also had a high dropout rate, which may have made the results difficult to interpret. Citalopram has also been studied
in pediatric patients with functional abdominal pain, with a trend toward efficacy. [Roohafza: 2014]
- Not FDA approved for use in children. In August 2011, the FDA issued a Drug Safety Communication warning of the potential for QT prolongation and Torsades de Pointes in patients taking citalopram at doses higher than 40mg daily and that citalopram should no longer be used at such doses. The FDA also discouraged use of citalopram at any dose in patients with cardiac conditions predisposing to arrhythmia, including congenital long QT syndrome.
- Available as brand name (e.g., Celexa) and generic in 10 mg, 20 mg, and 40 mg tablets and 10 mg/5 ml oral solution
- Starting dose for adolescents: 10mg once daily; initial target dose 10mg to 20mg once daily; dose range 10mg to 40mg once daily.
-
Escitalopram is the S-isomer of citalopram. Escitalopram has had 3 controlled trials. One controlled trial in adolescents aged 12 to 17
years had positive results (unpublished data, Forest Laboratories). Two other controlled trials [Wagner: 2006] and unpublished data, Forest Laboratories), did not show significant difference from placebo. Of note, a post-hoc analysis
of the data from the published negative study showed a significant difference from placebo for the adolescent age group.
- FDA approved for treatment of depression in adolescents aged 12 to 17 years (based on the strength of the positive study and data from a study of citalopram)
- Available as brand name (e.g., Lexapro) and generic in 5 mg, 10 mg, and 20 mg tablets and 5 mg/5 ml oral solution
- Starting dose for adolescents: 5mg to 10mg once daily, initial target dose 10mg once daily, dose range 10mg to 30mg once daily
- Tricyclic antidepressants (TCAs) have been available for many years but have been eclipsed by the SSRIs, largely due to SSRIs having fewer side effects and less toxicity. It is important for pediatric clinicians to know that multiple trials of TCAs have failed to show significant benefit compared to placebo for treatment of depression in children and adolescents. A Cochrane review from 2013 supported the same conclusion.
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Bupropion has no controlled studies for depression in children and adolescents. There is 1 open study of bupropion in children with
depression and comorbid ADHD that has positive results. [Daviss: 2001] Bupropion is used in adults for depression and smoking cessation. Unlike SSRIs, bupropion has little effect on anxiety. It
may be useful in patients with bipolar disorder and depression as it is less likely than other antidepressants to induce mania.
There is a small risk of generalized seizures with bupropion, which is higher at doses >300mg daily. Due to increased risk
of seizures, bupropion is contraindicated in patients with an active eating disorder.
- Not FDA approved for use in children
- Available as brand name (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban) and generic in 75 mg and 100 mg tablets; 100 mg, 150 mg, and 200 mg extended release (12 hour) tablets; 174 mg, 348 mg, and 522 mg extended release (24 hour) tablets (as hydrobromide); and 150 mg, 300 mg, and 450 mg extended release (24 hours) tablets (as hydrochloride)
- Starting doses in adolescents: bupropion SR 75mg twice daily, initial target dose 100mg twice daily, dose range 75mg to 150mg twice daily; bupropion XL (Wellbutrin XL) starting dose 150mg once daily, initial target dose 150mg to 300mg once daily, dose range 150mg to 450mg once daily.
- Venlafaxine (Effexor, Effexor XR) is an SNRI (serotonin-norepinephrine reuptake inhibitor) and thus possesses an additional mechanism of action compared with SSRIs. The spectrum of effects of venlafaxine is nonetheless similar to that of the SSRIs. In fact, at lower doses (<225 mg daily), the norepinephrine reuptake action is not present, effectively making venlafaxine an SSRI at these doses. There have been few studies of its use in children and adolescents. Venlafaxine was studied in a large RCT involving patients who continued to have depression despite adequate treatment with one SSRI, and was not significantly better in that context than a second SSRI; there was no placebo arm. [Brent: 2008] One unpublished study and one small, randomized controlled trial did not show significant benefits.[Boylan: 2007]Pooled results of these two studies showed a small benefit for adolescents only. Studies may have been hampered by a high rate of placebo response. Venlafaxine also has significant discontinuation symptoms that may begin within a few hours of a missed dose. For these reasons, venlafaxine is at best a second line medication for children and adolescents with depression.
- Desvenlafaxine SR (Pristiq) is an SNRI and is a form of the active metabolite of venlafaxine. Desvenlafaxine SR has had 1 controlled trial. [Weihs: 2018] This trial compared desvenlafaxine SR weight-based dosing to fluoxetine and placebo and was non-significant due to improvement in all study arms. Desvenlafaxine SR is therefore not a first-line medication for children and adolescents with depression.
- Duloxetine (Cymbalta) is an SNRI. Duloxetine has had 2 controlled trials.[Emslie: 2014] [Atkinson: 2014] Both studies compared duloxetine to fluoxetine (as a standard treatment) and placebo. Both studies showed no significant differences between treatments due to improvement in depression in all study arms (duloxetine at both fixed and flexible doses up to 120mg daily, fluoxetine up to 40mg daily, and placebo). Until more positive findings are produced, duloxetine would not be a first-line medication for children and adolescents with depression.
- Levomilnacipran (Fetzima) is the newest SNRI on the market, approved by FDA for treatment of depression in adults in July 2013. There is a controlled study in progress for adolescents with MDD: Clinical Trials for Levomilnacipran in Adolescents (clinicaltrials.gov).
- Mirtazapine (Remeron) has multiple actions at the CNS receptor level that may contribute to antidepressant effect. There have been two unpublished trials of mirtazapine for depression in children and adolescents. Neither trial demonstrated significant difference from placebo. As with venlafaxine, this lack of apparent effect may be due to high placebo response rates. Still, mirtazapine would not be a first-line medication choice for children and adolescents with depression.
- Vilazodone (Viibryd) inhibits serotonin reuptake and modulates serotonin receptors. It was approved by FDA for treatment of depression in adults in January 2011. A controlled study in pediatric MDD focused on adverse effects was completed in October 2018: Clinical Trials Vilazodone in Adolescents (clinicaltrials.com).
- Vortioxetine (Trintellix) also inhibits serotonin reuptake and modulates serotonin receptors. It was approved by FDA for treatment of depression in adults in September 2013; there have been no controlled studies of the efficacy of vortioxetine in depressed children or adolescents.
Use of antidepressant medication in children has become a controversial topic ever since the British Medications and Healthcare Regulatory Agency banned the use of all antidepressants except for fluoxetine in patients <18 years of age in the United Kingdom in 2003. This ban was instituted due to concerns about the potential for suicidal thoughts or behavior in patients taking antidepressant medication. Subsequent evaluation by the US FDA led to a black box warning in 2004 for all antidepressants stating that they may increase the risk of suicidal thinking and behavior in children and adolescents with major depressive disorder and other psychiatric disorders. The FDA added a similar warning in 2007 for young adults aged 18-24 years.
The FDA did not institute a ban on use of antidepressants in children and adolescents, nor did the agency revoke the approval of fluoxetine for treatment of depression in patients aged 7-18. The warning reflects an increased risk of suicidal thoughts or behaviors only, not an increased risk of completing suicide: No one in the studies evaluated by the FDA completed suicide. For those taking active medication, the risk of suicidal thoughts or behaviors was only 3.9%; while the placebo group was 1.8%. [Hammad: 2006]
An independent review of available data by the American Medical Association indicated that “a causal role for antidepressants in increasing suicides in children and adolescents has not been established. ...Concerns that antidepressants potentiate suicidal or self-injurious behavior need to be balanced by the clear risk of suicide in children and adolescents with untreated depression.” [Jane: 2016] Another analysis of all available antidepressant RCTS in youth suggests that antidepressants have benefits that may outweigh these risks. [Bridge: 2007] There is also data demonstrating a correlation between higher rates of SSRI prescriptions and reduction in child and adolescent suicide rates. [Gibbons: 2006]
Given concerns for SAEs, rational prescribing practices include making patients and parents aware of the safety concerns around antidepressant use. Patients who are started on antidepressant medication should be observed closely for clinical worsening, suicidal thoughts, or unusual changes in behavior. Families and caregivers should be advised to closely observe the patient and to communicate with the prescribing physician. Follow-up should occur within 1 week after a patient is newly started on an antidepressant.
Specialty Collaborations & Other Services
Psychiatry/Medication Management (see UT providers [56])
Can be very helpful in guiding and/or managing pharmacologic therapy, particularly for patients who do not respond promptly or well to standard medications.
Ask the Specialist
Resources for Clinicians
On the Web
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research,
and getting help for depression; American Academy of Child & Adolescent Psychiatry.
Resources for Primary Care (AACAP)
A resource center for clinicians treating substance use disorders and mental health issues. Includes practice parameters,
a guide for integrating mental health care into the medical home, and information about policy and advocacy; American Academy
of Child & Adolescent Psychiatry.
Helpful Articles
PubMed search for depression in children and adolescents, last two years
Cheung AH, Kozloff N, Sacks D.
Pediatric depression: an evidence-based update on treatment interventions.
Curr Psychiatry Rep.
2013;15(8):381.
PubMed abstract / Full Text
David-Ferdon C, Kaslow NJ.
Evidence-based psychosocial treatments for child and adolescent depression.
J Clin Child Adolesc Psychol.
2008;37(1):62-104.
PubMed abstract
Maalouf FT, Brent DA.
Child and adolescent depression intervention overview: what works, for whom and how well?.
Child Adolesc Psychiatr Clin N Am.
2012;21(2):299-312, viii.
PubMed abstract
March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J.
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents
With Depression Study (TADS) randomized controlled trial.
JAMA.
2004;292(7):807-20.
PubMed abstract
Wren FJ, Foy JM, Ibeziako PI.
Primary care management of child & adolescent depressive disorders.
Child Adolesc Psychiatr Clin N Am.
2012;21(2):401-19, ix-x.
PubMed abstract
Clinical Tools
Assessment Tools/Scales
Beck Depression Inventory-II
A self-administered, 21-item, 10-minute screen for depression for ages 13 years and older; available in Spanish or English
for purchase.
Center for Epidemiologic Studies - Depression Scale (CES-D) ( 171 KB)
A free, self-administered, 20-item, 10-minute screen for depression for ages 14 years and older.
Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders.
Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.
Toolkits
Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes
a variety of resources, checklists, intake and assessment forms, and patient education materials.
Resources for Patients & Families
Information on the Web
Children's Mental Health (MHA)
Policy, advocacy, information, and referral to maximize mental health for people of all ages; Mental Health America.
Depression (NAMI)
Explanations of treatment for various mental disorders, including depression, and suggestions for how to help yourself or
others who are struggling with mental health issues ; National Alliance on Mental Illness.
Teens & Young Adults (NAMI)
Focused information about adolescent depression, how to find help, and links to a teen mental health forum called Ok2Talk;
National Alliance on Mental Illness.
Depression in Children and Teens (AACAP)
Common symptoms of depression in children and teenagers; American Academy of Child and Adolescent Psychiatry.
Child and Adolescent Mental Health (NIMH)
Information about mental health conditions in children and adolescents, including a list of warning signs, featured videos,
and health hotlines; National Institute of Mental Health.
Childhood Depression: What Parents Need to Know (KidsHealth)
How to recognize depression in children, give support, and seek help.
National & Local Support
Utah National Alliance on Mental Illness (NAMI)
Utah chapter of the National Alliance on Mental Illness; provides advocacy and information about mental illnesses.
National Alliance of Mental Illness (NAMI)
A national organization provides information and resources for families and professionals, including a helpline, local chapter
resources, and advocacy, links to state chapters, information about conferences, and links to additional resources.
Studies/Registries
Depression in Children and Adolescents (ClinicalTrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.
Services for Patients & Families in Utah (UT)
| Service Categories | # of providers* in: | UT | NW | Other states (4) (show) | | NM | NV | OH | RI |
|---|---|---|---|---|---|---|---|---|---|
| General Counseling Services | 372 | 1 | 3 | 209 | 1 | 30 | |||
| Psychiatry/Medication Management | 56 | 2 | 49 | 79 | |||||
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
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