Overview
Definition:
Depression in pediatrics is a mood disorder characterized by persistent sadness and loss of interest, affecting a child's or adolescent's ability to function
Suicide is the act of intentionally causing one's own death
Screening involves systematic identification of youth at risk.
Epidemiology:
Approximately 5% of children and 10-20% of adolescents experience depression annually
Suicide is a leading cause of death in adolescents, with significant increases observed globally
Risk factors include family history of mental illness, trauma, and chronic illness.
Clinical Significance:
Untreated depression can lead to academic failure, social isolation, substance abuse, and increased risk of suicide
Early identification and intervention are crucial for improving outcomes and preventing tragic loss of life
Pediatricians play a vital role in initial screening.
Clinical Presentation
Symptoms:
Irritability or anger, instead of sadness
Persistent sadness or emptiness
Loss of interest in previously enjoyed activities
Changes in appetite or weight (increase or decrease)
Sleep disturbances (insomnia or hypersomnia)
Fatigue or low energy
Feelings of worthlessness or guilt
Difficulty concentrating or making decisions
Recurrent thoughts of death or suicide, including suicide attempts.
Signs:
Poor eye contact
Slowed speech or movement
Psychomotor agitation or retardation
Crying spells
Social withdrawal
Academic decline
Neglect of personal hygiene
Expressing hopelessness
Self-harm behaviors.
Diagnostic Criteria:
DSM-5 criteria for Major Depressive Disorder (MDD) or Persistent Depressive Disorder (Dysthymia) in children and adolescents
Diagnosis requires a minimum number of symptoms present for at least two weeks, causing significant impairment in functioning
Specific screening tools like the PHQ-A are used to identify potential cases.
Screening Tools And Approach
History Taking:
Comprehensive history focusing on mood, anhedonia, sleep, appetite, energy levels, concentration, and feelings of worthlessness
Inquire about changes in behavior, academic performance, and social interactions
Screen for family history of depression, suicide attempts, or substance abuse
Ask directly about suicidal ideation, plans, and intent using age-appropriate language.
Physical Examination:
General physical examination to rule out organic causes of mood changes (e.g., hypothyroidism, anemia)
Assess vital signs, neurological status, and general appearance
A thorough exam can sometimes reveal clues to underlying issues or self-harm.
Investigations:
Routine laboratory investigations are typically not indicated for diagnosing uncomplicated depression
Consider thyroid function tests (TSH), complete blood count (CBC), and vitamin B12/folate levels if there is suspicion of an underlying organic cause or atypical presentation
Neuroimaging is generally not recommended for routine depression screening.
Differential Diagnosis:
Adjustment disorder with depressed mood
Bipolar disorder (depressive episode)
Grief reaction
Substance-induced mood disorder
Attention-deficit/hyperactivity disorder (ADHD)
Oppositional defiant disorder (ODD)
Anxiety disorders
Medical conditions mimicking depression (e.g., chronic fatigue syndrome, endocrine disorders).
Phq A Screening Tool
Description:
The Patient Health Questionnaire-Adolescent (PHQ-A) is a self-report measure designed to screen for depression in adolescents aged 12-17 years
It is a derivative of the PHQ-9 and assesses symptom severity and functional impairment over the past two weeks.
Scoring And Interpretation:
The PHQ-A consists of 9 items, each rated on a 4-point scale from 0 (not at all) to 3 (nearly every day)
Scores range from 0 to 27
A total score of 10 or higher suggests moderate to severe depressive symptoms and warrants further evaluation
Specific cutoffs may vary, with higher scores indicating greater likelihood of depression.
Clinical Utility:
The PHQ-A is a validated, brief, and easy-to-administer tool for use in primary care settings
It helps identify adolescents who may benefit from further assessment by a mental health professional
It is particularly useful for routine screening during well-child visits or when behavioral changes are noted.
Safety Planning Intervention
Definition:
Safety planning is a collaborative process between a clinician and an individual at risk of suicide to develop a personalized plan to manage suicidal crises
It focuses on identifying triggers, coping strategies, and sources of support.
Components Of A Safety Plan:
Warning signs that a crisis is developing
Internal coping strategies (e.g., relaxation techniques, distraction)
People and social settings that provide distraction
People who can offer support and help in a crisis
Professionals or agencies to contact in a crisis (including emergency services)
Making the environment safe by removing access to lethal means.
Implementation And Follow Up:
The safety plan should be developed in partnership with the adolescent and, if appropriate, their family
It should be written down, accessible, and reviewed regularly
Follow-up is crucial to assess the plan's effectiveness and make adjustments as needed
This often involves scheduled mental health appointments.
Management Of Pediatric Depression
Initial Management:
For mild to moderate depression, psychotherapy (especially Cognitive Behavioral Therapy - CBT and Interpersonal Therapy - IPT) is the first-line treatment
For severe depression or when psychotherapy alone is insufficient, consider pharmacotherapy.
Medical Management:
Selective Serotonin Reuptake Inhibitors (SSRIs) are the most commonly prescribed antidepressants
Fluoxetine is FDA-approved for pediatric depression
Start with a low dose and titrate slowly
Monitor closely for side effects, particularly the emergence of suicidal ideation (black box warning)
Other SSRIs like escitalopram and sertraline may also be used off-label
Therapy should be initiated concurrently.
Psychosocial Interventions:
Individual psychotherapy (CBT, IPT)
Family therapy to improve communication and support
School-based interventions to address academic and social difficulties
Psychoeducation for the child and family about depression and its management.
Suicidal Risk Management:
For adolescents with active suicidal intent or a recent suicide attempt, hospitalization may be necessary
Close monitoring, removal of means, and intensive psychiatric treatment are paramount
Involve child protective services if neglect or abuse is a contributing factor
Ongoing safety planning is essential.
Key Points
Exam Focus:
Understand the PHQ-A's role in screening
Know the DSM-5 criteria for pediatric depression
Recognize that SSRIs are first-line pharmacotherapy but require careful monitoring for suicidality
Safety planning is a critical intervention for at-risk youth.
Clinical Pearls:
Always ask directly about suicidal thoughts and plans
Irritability can be a primary symptom of depression in children
Involve parents/guardians in assessment and treatment whenever possible
A collaborative safety plan is more effective than a directive one.
Common Mistakes:
Underestimating the prevalence of depression and suicide risk in pediatrics
Over-reliance on pharmacological treatment without psychotherapy
Failing to conduct thorough suicide risk assessments
Not developing a comprehensive, actionable safety plan
Ignoring behavioral changes as potential indicators of distress.