Depression in Children and Adolescents

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Primary care physicians are often the first health care providers to have contact with depressed children and adolescents. This article discusses the epidemiology, clinical features, comorbid conditions, risk and protective factors, treatment modalities, and clinical course of early-onset depression.

Section snippets

Epidemiology

An oft-quoted review of depression in childhood and adolescence [2] reports the prevalence of depression in community settings as 0.4% to 2.5% in children and 0.4% to 8.3% in adolescents. In a more recent community study of children without depression who were initially assessed between the ages of 9 and 13 years, more than 7% of boys and almost 12% of girls developed a depressive disorder by the age of 16 years [3]. From a preventative mental health perspective, it may be important to ask at

Diagnostic features

The diagnosis of MDD and DD in younger patients follows, in general, the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition [text revision] (DSM-IV-TR) [10]. A convenient way to remember the symptoms of MDD is the use of the mnemonic “SIGECAPS” (Box 1).

Modifications in the diagnostic criteria for MDD or DD, which are established for adults, depend on the age of the patient. For example, younger patients with MDD or DD can have a mood that is irritable

Anxiety disorders

There is a high degree of co-occurrence of depression and anxiety in younger people; having one of the disorders predicts the presence of the other in anywhere from around 16% to 62% of clinically identified samples [16]. Considering youth with depression, approximately 20% to 75% also have an anxiety disorder [17]. As a group, the anxiety disorders tend to develop before the depressive disorders in children who are comorbid for both [18], but there is debate as to whether the anxiety actually

Risk factors

Risk factors for depression in childhood and adolescence can be divided into four major categories: genetics, environmental factors, negative life events, and child characteristics [35].

Protective factors

In addition to preventing, minimizing, or eliminating the previously noted risk factors, the development of depression in children and adolescents may be prevented or reduced by certain protective factors.

Psychotherapy

Although psychotherapy has been shown to be efficacious in the treatment of depression in younger people, most of the research has been conducted using cognitive-behavioral therapy (CBT) for acute-phase treatment of adolescents [61], [62]. There is less research involving interpersonal therapy (IPT), family therapy, and group therapy; less research in younger children; and less research on the use of these therapies as maintenance treatments or as relapse preventatives. Nevertheless, evolving

Clinical course

Diligence in identifying cases of child and adolescent depression and aggressive treatment and follow-up are crucial, because these young people simply do not “grow out of it.” A study from the United Kingdom [80] re-evaluated a cohort of young adults who had been diagnosed with depression a mean of 7.8 years earlier. At that later assessment, 40% had experienced recurrent depression at some time and 18% had essentially remained depressed since childhood. The greatest concern related to missed

Consultation and referral

Primary care physicians usually have the first contact with a depressed child or adolescent and, in most cases, are able to provide effective treatment. Questions that may arise when treatment is not going well include the following. When should I ask for a psychiatric consult? When should I refer to a child and adolescent psychiatrist? Richardson and Katzenellenbogen [35] have recommended considering a mental health evaluation of the child when there is severity, comorbidity, suicidality, or

Summary

The development of depression in children and adolescents is complex and multifactorial. Similarly, the effective resolution of a depressive episode requires a multidisciplinary approach. Primary care physicians are in a unique position to provide early assessment and treatment to their depressed and vulnerable younger patients.

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