The prevalence of depression is estimated to be 2.8 percent in children younger than 13 years and 5.6 percent in adolescents 13 to 18 years of age.¹ The incidence of depression among children and adolescents is of great concern because of the acute and lasting consequences associated with depressive disorders. Approximately 60 percent of adolescents with depression have recurrences throughout adulthood.² Furthermore, adults with a history of adolescent depression have a higher rate of suicide than those without such a history.² Adolescent-onset depression has been associated with abuse and neglect³; poor academic performance; substance use; early pregnancy; and disruptions in social, employment, and family settings into adulthood.^4–6 Although the prevalence of adolescent depression is high, it is significantly underdiagnosed and undertreated.⁷ Because of the lack of mental health care professionals, family physicians are often responsible for detecting and treating childhood and adolescent depression.^8–10

Risk Factors

Although risk factors for childhood and adolescent depression can be categorized as biologic, psychologic, or environmental (Table 1), these factors are often intertwined.^7,8,11,12 For example, parental depression is strongly associated with childhood and adolescent depression; children of parents with depression have a threefold greater risk of developing depression than those whose parents have no such history.^13,14 Furthermore, the age when risk factors occur may predict future depression. Children diagnosed with a health condition such as diabetes mellitus or asthma between the ages of three and five years are likely to have a major depressive episode.¹² Likewise, children five years of age who were rated by teachers as being hostile were at greater risk of depression.¹²

Screening

The U.S. Preventive Services Task Force concluded that screening adolescents 12 to 18 years of age may lead to earlier detection and treatment of depression.¹⁵ There was insufficient evidence to recommended routine screening for younger children in primary care settings. The use of screening tools in children with at least one risk factor may be more helpful than universal screening. These tools can also indicate the severity of depressive symptoms. Screening tools include the Beck Depression Inventory for Primary Care for adolescents 12 to 18 years of age, and the Children's Depression Inventory for children and adolescents seven to 17 years of age.^16,17 The Beck Depression Inventory for Primary Care is a self-report tool that includes seven questions that are scored from zero to three points each (Figure 1).^17,18 A score of at least 4 warrants further evaluation for depression.¹⁹ The Children's Depression Inventory is available in self-report, parent-report, and teacher-report versions; scores are converted to a T-score, with scores of 65 or more indicating clinical significance.²⁰ Additional screening tools are described in Table 2.^21–24 Screening tools should be selected based on patient's age, reading level, and time available to complete the measures.

Presentation

Although diagnostic criteria for depression are the same for children and adults (Table 3²⁵ ), the manner in which these symptoms present may be different.²⁵ Adolescents with depression are more likely to experience anhedonia, boredom, hopelessness, hypersomnia, weight change (including failure to reach appropriate weight milestones), alcohol or drug use, and suicide attempts. Younger children are more likely to have somatic symptoms, restlessness, separation anxiety, phobias, and hallucinations.²⁶ The child's cognitive level should be considered; for example, younger children may appear sad but have difficulty verbalizing their mood.²⁷ Differences have been found between parent reports and self-reports of depressive symptoms. Parents are more likely to indicate externalized symptoms such as irritability, whereas children are more likely to report internalized symptoms such as depressed mood.⁸

Diagnosis

When considering a diagnosis of depression, physicians must also consider likely medical causes of the presenting symptoms, such as hyper- or hypothyroidism, anemia, or use of certain medications, including isotretinoin (Table 4).⁸ If the patient's mood is better explained by medical causes, the diagnosis of major depressive disorder is not appropriate.²⁵

Other psychological illnesses have presentations in children and adolescents that are similar to depression, especially adjustment, dysthymic, and bipolar disorders. Adjustment disorders are characterized by “a psychological response to an identifiable stressor or stressors.”²⁵ Symptoms develop within three months of the stressor and are in excess of what would be expected, or they cause significant impairment. Adjustment disorder with depressed mood can be mistaken for major depressive disorder; symptoms of both conditions include depressed mood, tearfulness, and feelings of hopelessness. However, the symptoms of adjustment disorder are related to a specific event and do not meet all criteria of a major depressive episode.²⁵

Dysthymic disorder in children and adolescents is characterized by depressed mood on most days for one year. Patients with dysthymia meet a subset of criteria for major depression, but the course of the illness is longer and the symptoms are less severe. Depressive symptoms may manifest as irritability in children and adolescents, and patients often have low self-esteem and poor social skills.

Bipolar disorder consists of periods of major depression alternating with mania or hypomania, during which patients have increased irritability, energy, grandiosity, and/or racing thoughts. It is important to rule out bipolar disorder when diagnosing depression, because antidepressant medications can initiate manic symptoms.

Risk Assessment for Suicide

The presence of a psychiatric disorder is one of the strongest correlates for suicide across age groups.²⁸ According to the Centers for Disease Control and Prevention, the incidence of suicide in children 10 to 14 years of age was approximately 0.9 per 100,000 in 2007, and the incidence in adolescents 15 to 19 years of age was 6.9 per 100,000.²⁹ The methods by which suicide was completed include firearms, suffocation, and poisoning; children most often use suffocation, whereas adolescents are more likely to use firearms.²⁹ Therefore, routine and ongoing assessment of suicidality in children and adolescents with depression is recommended, especially in patients who are receiving antidepressant medication.^30,31

Asking about suicide or using depression screening tools can be a means for assessing suicidal ideation in children and adolescents in the primary care setting. However, further inquiry into patient symptoms may be required because some tools lack specificity or are prone to oversensitivity. If a patient has suicidal thoughts, further assessment should include questions about the frequency of thoughts; the presence and specificity of a plan; the lethality or availability of means to follow through with the plan; whether there are protective factors, such as social support; and whether there are any other factors, such as substance use or a previous suicide attempt. If it is determined that a patient is at risk of self-harm, urgent referral to a mental health professional or emergency department is warranted.

Interventions for patients at lower risk of self-harm include involving parents or caregivers to provide close observation of the patient, and removing any weapons or means to self-harm. The frequency of follow-up visits may be increased, and patients may benefit from education on how to seek assistance after hours (e.g., emergency departments, crisis hotlines).^8,30–32 Parents and family members should be educated about behaviors that would warrant immediate follow-up, such as increased suicidal ideation, impulsivity, irritability, restlessness, pressured speech, or psychomotor agitation.^31,33

Treatment

Treatment of childhood and adolescent depression consists of psychotherapy, pharmacotherapy, or a combination of these. Treatment should correspond to the level of depression, patient preferences, the developmental level of the patient, associated risk factors, and availability of services.⁸ Patient and family education about the associated risks and benefits of treatment, expectations regarding patient monitoring, and follow-up should be included.³³

PSYCHOTHERAPY

The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry recommend that psychotherapy always be a component of treatment for childhood and adolescent depression.³³ They recommend psychotherapy as an acceptable treatment option for patients with milder depression, and a combination of medication and psychotherapy in those with moderate to severe depression.

Cognitive behavior therapy (CBT) and interpersonal therapy have been proven effective in the treatment of adolescent depression, and CBT has been proven effective in the treatment of childhood depression. CBT usually consists of behavioral activation techniques and methods to increase coping skills, improve communication skills and peer relationships, solve problems, combat negative thinking patterns, and regulate emotions.^8,34–36 In contrast, interpersonal therapy generally focuses on adapting to changes in relationships, transitioning personal roles, and forming interpersonal relationships.^8,36 The effects of CBT on depressive symptoms are moderate,^37,38 but it has not been proven more effective than placebo for treating acute depression in adolescents.³⁹ A combination of CBT and medication has been shown to be more effective than medication alone in attaining remission of depression.^37,40 Interpersonal therapy has not been compared with medication, combination treatment, or placebo, but it has been proven more effective than wait-list control groups with no therapy, and as effective or more effective than CBT.^41,42

PHARMACOTHERAPY

Although psychotherapy is a major component in the treatment of childhood and adolescent depression, adjuvant use of medication is sometimes appropriate. Considerations for initiating antidepressant therapy include depression severity and history (Table 5).^43,44 Extrapolation of adult data on antidepressant medications to children and adolescents may not be accurate, because neural pathways may not be fully developed, and serotonin and norepinephrine systems have different maturation rates.⁴⁵

Tricyclic antidepressants were previously used to treat depression in children, but studies have shown little to no benefit in adolescents and children.⁴⁶ Consensus guidelines recommend fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft) as first-line treatments for moderate to severe depression in children and adolescents.⁴⁷ A Cochrane review found that fluoxetine was the only agent with consistent evidence (from three randomized trials) that it is effective in decreasing depressive symptoms.⁴⁸ Escitalopram (Lexapro) is also licensed for the treatment of depression in adolescents 12 years and older. Treatment should begin at the lowest dosage available and titrated according to the patient's response and adverse effects. If initial first-line therapy is ineffective, another first-line agent should be considered. All antidepressants have a boxed warning for an increased risk of suicide; therefore, close monitoring is recommended (e.g., weekly telephone calls, scheduled visits for the first month of therapy) to assess for suicidality and other adverse effects, such as gastrointestinal effects, nervousness, headache, and restlessness.^47,49 If there is limited improvement or no remission of symptoms after all first-line medications have been attempted, a psychiatric consultation is strongly recommended.⁵⁰

Treatment Duration and Referral

Treatment of depression in children and adolescents should continue for six months after remission.^49,51 A double-blind, placebo-controlled trial of adolescents receiving fluoxetine found that those who received placebo after treatment had a shorter time to relapse than those who continued therapy.⁵² Patients in the fluoxetine group were significantly less likely to have a relapse of depressive symptoms (34 versus 60 percent). The decision to continue treatment for four to six months after remission of symptoms should be based on prior recurrent episodes of depression and current psychological and social stressors. Children younger than 11 years and those with chronic depression, comorbid substance use, psychiatric disorders, suicidality with plan, or lack of parental engagement in treatment should be referred to a psychiatrist.^44,52

Data Sources: We searched Essential Evidence Plus, the Agency for Healthcare Research and Quality evidence reports, the Cochrane Database of Systematic Reviews, Clinical Evidence, the National Guideline Clearinghouse, the U.S. Preventive Services Task Force, PubMed, Ovid Medline, and PsycINFO using the keywords childhood and adolescent depression, major depression and adolescents, major depression and childhood, major depression and children, depression and children, and depression and adolescents. The search included reviews, meta-analyses, randomized controlled trials, and clinical trials. Search dates: March 5 and 11, 2011.