Depression in children and adolescents

Childhood and adolescent depression is often recurrent and continues episodically into adulthood. It can occur with comorbid psychiatric disorders, increased risk of suicide, substance abuse and behavioural problems. Depression affects the whole of a person's life, impairing occupational, social, emotional and physical health and carrying considerable stigma.¹

How common is childhood depression? (Epidemiology)²

• The prevalence of childhood depression has been estimated to be 1% in pre-pubertal children and around 3% in post-pubertal young people.

• In pre-pubertal children, there is no sex difference in prevalence. However, in post-pubertal young people the prevalence in females may be higher than that of males, whose prevalence continues to rise but at a much slower rate.

• Approximately 7.6% of children aged 12 years and older have had moderate to severe depression.

• Depression in children and young people tends to occur in conjunction with other mental health conditions.

• Looked-after children and young people, and those in correctional institutions, have a particularly high prevalence of all mental disorders, including depression.

Risk factors¹

• Family discord.

• Bullying.

• Physical, sexual or emotional abuse.

• History of parental depression.

• Ethnic and cultural factors.

• Homelessness.

• Refugee status.

• Living in institutional settings.

Symptoms of depression in children and adolescents²

The diagnosis is often missed and there is limited evidence that primary screening tools may accurately identify depressed adolescents.³

• Often with somatic symptoms and may also have features of anxiety.

• Sometimes only presents as poor functioning at school, socially, or at home.

• It may even masquerade as bad behaviour, particularly in boys.

• Mood is characteristically much more variable and less pervasive than in adults, and rapid mood swings often occur.

• The fact that children are able to enjoy some aspects of their lives shouldn't preclude the diagnosis of depression.

• Features as seen in depression in adults:
  

  • Persistent sadness or low mood (or irritability).

  • Loss of interest or loss of pleasure (anhedonia).

  • Reduced energy leading to increased fatiguability and diminished activity.

  • Being socially withdrawn.

  • Reduced self-esteem and self-confidence.

  • Ideas of guilt and unworthiness.

  • Reduced concentration and attention.

  • Bleak and pessimistic views of the future.

  • Ideas or acts of self-harm or suicide.

  • Disturbed sleep; insomnia or hypersomnia.

  • Eating increased or decreased, particularly if associated with weight change.

• Features common in childhood:
  

  • Running away from home.

  • Separation anxiety and possibly school refusal.

  • Complaints of boredom.

  • Poor school performance.

  • Antisocial behaviour.

• Young primary school children may present with sadness and helplessness; slightly older children with feelings of being unloved and unfairly treated. Guilt and despair may be more prominent in teenagers.

• Consider the possibility of concealed contributory factors - eg, past child abuse, bullying.

• Parents may not always be aware of depression in their children.

• Assessment is frequently difficult and many questions may only be answered by silence or a shrug.

• Adolescents with conduct disorders can be manipulative and extremely difficult to assess - an urgent second opinion is frequently required.

• Always ask about suicide ideation and thoughts of self-harm:

  • Note any past attempts, as about 15-20% make further attempts (males, those with conduct disorder, excessive alcohol use, hopelessness and those in local authority care are at increased risk).

  • Self-harm can be regarded as a form of communication, not always 'picked up' and sometimes difficult to decipher the teenager's exact intentions. Deliberate self-harm is common in adolescents, especially females.⁴

  • Refer urgently if the risk is considered significant.

Particular attention should be paid, when dealing with depression in young people, to:¹

• Confidentiality.

• The young person's consent, including Gillick competence (children under the age of 16 can consent to their own treatment if they're believed to have enough intelligence, competence and understanding to appreciate fully what's involved in their treatment).

• Parental consent.

• Child protection.

• The use of the Mental Health Act (compulsory hospitalisation) in young people.

• The use of the Mental Capacity Act in young people.

• The use of the Children Act.⁵

Treatment^{1 2}

See the National Institute for Health and Care Excellence (NICE) guideline for further details of the management of mild, moderate and severe depression in children and young people.

It is common for management to be based in secondary care with support from primary care. This reflects frequent difficulties in diagnosis and management, and variable access to psychological interventions within primary care.

However, primary care services (including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services) may be appropriate in cases with factors such as:

• Exposure to a single undesirable event in the absence of other risk factors for depression.

• Exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm.

• Exposure to a recent undesirable life event where one or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child/young person.

• Mild depression without comorbidity.

Refer to Child and Adolescent Mental Health Services (CAMHS), which includes clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists, in cases with the following factors:

• Depression with two or more other risk factors for depression (eg, age, gender, family discord, bullying, physical, sexual or emotional abuse, homelessness, refugee status or living in institutional settings).

• Depression where one or more family members (parents or children) have multiple-risk histories for depression.

• Mild depression in those who have not responded to interventions after 2-3 months.

• Moderate or severe depression (including psychotic depression).

• Signs of a recurrence of depression in those who have recovered from previous moderate or severe depression.

• Unexplained self-neglect of at least one month's duration that could be harmful to their physical health.

• Active suicidal ideas or plans.

• Referral requested by a young person or their parents or carers.

Social interventions

• Addressing any sources of distress (eg, bullying) and removing opportunities for self-harm (eg, paracetamol at home).

Psychological interventions

• Computerised (digital) cognitive behavioural therapy (cCBT) should be offered as a first-line treatment to children and young people aged 5 to 18 years with mild depression continuing after two weeks of watchful waiting. Group CBT, group non-directive supportive therapy, group interpersonal psychotherapy (IPT) and group mindfulness should also be considered as first-line options.

• If the above are not suitable or would not meet the child's needs, attachment-based family therapy or individual CBT should be considered.

• Children and young people aged 5-11 years with moderate-to-severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual cCBT, family therapy, psychodynamic psychotherapy or family-based interpersonal therapy(IPT)).

• Children and young people aged 12-18 years should be offered individual CBT for at least three months or, if this would not meet their needs or would be unsuitable, IPT for adolescents, attachment-based or systemic family therapy, brief psychosocial intervention or psychodynamic psychotherapy.

• Counsellors, sympathetic teachers and youth workers may be a resource to help children and young people.

• The evidence surrounding combination therapy with psychological interventions and antidepressants is limited. A Cochrane review showed there is limited evidence that combination therapy with psychological interventions and antidepressants is more effective than just antidepressants.⁶

• Patient and carer preferences and values, as well as the young person's maturity and personal circumstances should, if appropriate, be taken into account in determining the choice of psychological therapy.¹

Medication⁷

• The overall evidence may be limited but NICE recommends that antidepressant medication should only be used in combination with concurrent psychological therapy.

• Fluoxetine should be prescribed, as this is the only antidepressant for which trials show that the benefits outweigh the risks.

• In 2008, after a meta-analysis of data on antidepressants including selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine (noradrenaline) reuptake inhibitors (SNRIs), the Medicines and Healthcare products Regulatory Agency (MHRA) has stated that the risk of suicidal acts and behaviour is increased with the use of SSRIs or SNRIs in young people aged up to 25 years.⁸

• A Cochrane review of the newer antidepressants highlighted the increased risk of suicide-related outcomes in children and adolescents treated with antidepressant medications.

• The MHRA has stated that the risks of sertraline, citalopram, escitalopram, paroxetine, venlafaxine, and mirtazapine outweigh the benefits when used in children and adolescents with depression and should not be used in this patient group. However, it has been recognised that specialists may use these medications on occasions in response to individual clinical need.⁸

• NICE recommends that tricyclics should not be used to treat depression in children and young people.

• The risk of suicide is greatest in the early stages of SSRI treatment. This may be due to the fact that the medications need to be taken for several weeks before they are effective in treating depression (which is itself associated with an increased risk of suicidal behaviour). Children and adolescents should be carefully monitored for any increase in suicidal behaviour, self-harm or hostility.

Electroconvulsive therapy (ECT)

• Only consider electroconvulsive therapy (ECT) for young people (12-18 years) with very severe depression and either life-threatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments.

• ECT is used extremely rarely in young people (12-18 years) and only after careful assessment by a practitioner experienced in its use, and in a specialised environment.

• ECT should not be used in the treatment of depression in children (5-11 years).

Prognosis^{1 2}

• About 10% of children and young people with depression recover spontaneously within three months.

• At 12 months, 50% remain clinically depressed, and 20-30% at 24 months.

• About 30% of children and young people with depression have recurrences within five years and many of these individuals develop episodes into adult life.

• Those who develop a recurrent or chronic depression extending into adulthood are likely to suffer considerable disability and impairment.

Prevention

Preventative psychological and educational interventions may be effective. However, there is currently insufficient evidence to support the implementation of depression prevention programmes.⁹