Depression is the name given to a cluster of symptoms and behaviours resulting in impairment of personal and/or social functioning. Symptoms typically seen are: changes in mood e.g., sadness, irritability and anhedonia (loss of pleasure); cognitive changes e.g., slow functioning; low self-esteem and physical changes e.g., reduced activity, changes in weight. Epidemiology Depression in children (i.e., under 18 years) has a prevalence of around 1% in pre-pubertal children and 3% in post-pubertal young people. Post-pubertal, the prevalence is higher in females1. The majority of depression in adults can be traced back to adolescence. Part 1: Ophelia* is a 14-year-old girl who has recently moved into foster care following confirmed allegations of neglect while in the care of her mother. Her foster carer notices that she seems quite withdrawn. Ophelia has an appointment with a paediatrician as a Looked After Child, and her foster carer mentions this at the appointment. Risk Factors Depression usually has a multi-factorial cause and in can sometimes be difficult to identify a single trigger for a depressive episode. Risk factors include (but are not limited too): personal chronic illness or disease genetic susceptibility – twin studies have shown 37% heritability 2 family history of mental health disorder and/or depression familial chronic illness abuse e.g., physical, emotional, sexual or neglect (recent or historical) negative life events e.g., divorce, bereavement, domestic violence drug and alcohol use bullying increased demands e.g., academic pressures, caring responsibility; competitive sports female gender identity confusion/non-acceptance e.g., homosexual, transgender Part 2: The paediatrician has not previously met Ophelia and unfortunately her previous notes have not made it to the appointment. The foster carer explains that Ophelia was removed from her mother’s care due to neglect. Her mother had a “mental health problem” and was strongly suspected to be an alcoholic. Ophelia’s father is not involved. What risk factors for depression can you identify? Clinical Features In the DSM-V and ICD-11 there are numerous sub-types of depression. The broadest and most commonly seen types are major depressive disorder (MDD) and persistent depressive disorder (PDD). The diagnostic criteria are similar for both DSM-V and ICD-11. Major Depressive Disorder (MDD): At least five characteristic symptoms of depression over a 2-week period At least one key symptom must have a significant impact on functioning in more than one area of life e.g., home and school MDD can be further sub-divided into mild, moderate and severe (clinical decision). The symptoms underlined are characteristic of depression. Mood Changes Cognitive changes Physical Changes Low mood Low self-esteem/self-worth Disordered sleep Irritability Psychomotor retardation or agitation Change in appetite Anhedonia Anxiety Change in weight Hopelessness (Only in ICD-11 as part of the 5+ diagnostic symptoms) Recurrent thoughts of death Decreased energy Suicidal ideation Fatigue Loss of interest in appearance Poor personal hygiene Persistent Depressive Disorder (PDD): A chronic form of MDD Sad or irritable mood that has lasted at least 1 year with at least 2 other symptoms. Symptom-free for no longer than 2 consecutive months within the year. A diagnosis of depression is a clinical one based mostly on the history, however and child or young person presented with suspicion of a depressive illness requires a through history and examination to exclude any differential diagnoses. Part 3: Ophelia is a slight girl who is sitting with her head down, mumbling answers. She is wearing trousers and a hoodie covering her arms, and the hood is pulled up. She is asked to describe how she is feeling. She describes feeling sad all the time and is struggling to fall asleep at night as her “brain won’t stop”. She always feels tired. Her mother would often tell her that she was useless and that she was fat and lazy, especially when she was drunk. As a result, she doesn’t eat much and has noticed that she has lost weight. She still feels that she doesn’t like the way she looks. She has never had a boyfriend, as “no one likes me”. She doesn’t like to leave the house and doesn’t want to do anything that the foster carer suggests. She wants to stay in her room. She has recently failed some school exams. She admits to self-harming and reluctantly shows some marks on her forearms, both old scars and new injuries. She has been feeling like this for a few months. What symptoms can you identify in Ophelia, and does she meet the criteria for a diagnosis? Differentials Differentials include (but are not limited to): Anaemia Vitamin deficiency Thyroid disorder Other mental health disorders e.g., anxiety, anorexia nervosa Chronic fatigue syndrome Long COVID. Long COVID is an area of ongoing research, but there is emerging evidence in both children and adults of features seen as part of the diagnosis. Some of these features are also seen in depression.3 Investigations Laboratory investigations are not always indicated but you could consider a full blood count (with differential), thyroid-function tests. ferritin and vitamin D levels to exclude some of the differential listed above. Management Mild Initially 2 weeks of “watchful waiting” with a planned follow-up Discussion with the young person and their family about appropriate interventions Cognitive behavioural therapy (CBT) – group or individual Group non-directive supportive therapy (NDST) Group interpersonal psychotherapy (IPT) Attachment based family therapy Moderate and Severe Should be seen by the CAMHS team For 5–11-year-olds Family-based IPT Family therapy Psychodynamic psychotherapy Individual CBT For 12–18-year-olds IPT-A (for adolescents) Family therapy Psychosocial intervention Psychodynamic psychotherapy Severe Depression Anti-depressants can be used in combination with psychological therapy. Fluoxetine is first-line. If fluoxetine is ineffective or not tolerated, sertraline or citalopram could be used as second line options Part 4: Ophelia receives individual CBT with a psychologist, and they talk extensively about her mother and the abuse she received at home. After fortnightly sessions for 2 months, there has been no improvement in her symptoms. She has become more withdrawn and is now refusing to attend school. Her voice is flat and she makes no eye contact. She has mentioned a few times in her appointments about not seeing the point of being here as no-one wants her. She has talked about a bridge where she spends time looking over the edge and thinking about not being here anymore. Ophelia is seen by a psychiatrist and after assessment given the diagnosis of severe depression. It is agreed that she can start fluoxetine alongside her CBT. What side effects of fluoxetine are you aware of? Fluoxetine is an SSRI (selective-serotonin reuptake inhibitor) and is first line for severe depression in under 18s, alongside psychotherapy. SSRI should be commenced and initially prescribed by a specialist i.e., a psychiatrist Common side effects include headaches, feeling nauseous, anxiety and gastrointestinal disturbance. Rarely fluoxetine can increase suicidal thoughts and there is a risk of serotonin syndrome. Psychotherapies CBT – Psychotherapy where negative thoughts are challenged to try and change mood disorders and unwanted behaviours. NDST – Sessions with a professional which is led by the participant. Also called counselling IPT – Psychotherapy that aims to improve interpersonal relationships with a focus on the current state, as opposed to historical issues. Family Therapy – Group psychotherapy designed to improve inter-familial relationships Psychodynamic Psychotherapy – Focus on unconscious processes that manifest as unwanted behaviours. Aims to improve self-awareness and understanding of past influences. Complications and Prognosis The most serious complications of depression are the impact on the individual’s life and relationships and suicide. According to the Office of National Statistics the number of suicides in young people aged between 15 and 19 is at the highest it has been for 30 years. Approximately 10% of children and young people with depression recover without intervention within 3 months, 50% recovered at 12 months and 70-80% by 2 years. Around 30% of those with depression have a reoccurrence within 5 years. References (1) National Institute for Health and Care Excellence Clinical Knowledge Summary. Depression in children [Internet]. [London]: NICE; 2020. Available from https://cks.nice.org.uk/topics/depression-in-children (2) Shadrina M, Bondarenko EA, Slominsky PA. Genetics Factors in Major Depression Disease. Front Psychiatry. 2018 Jul 23;9:334. (3) Morello R, Mariani F, Mastrantoni L, De Rose C, Zampino G, Munblit D, Sigfrid L, Valentini P, Buonsenso D. Risk factors for post-COVID-19 condition (Long Covid) in children: a prospective cohort study. EClinicalMedicine. 2023 May Do you think you’re ready? Take the quiz below Pro Feature - Quiz Depression Question 1 of 3 Submitting... Skip Next Rate question: You scored 0% Skipped: 0/3 1000+ More Questions Available Upgrade to TeachMePaediatrics Pro Challenge yourself with over 1000 multiple-choice questions to reinforce learning Learn More Rate This Article