Essentials of Diagnosis
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions and hallucinations.
depressed mood. Note: In children and adolescents, can be irritable mood
loss of interest or pleasure (anhedonia)
significant weight loss when not dieting or weight gain, or decrease or increase in appetite. Note: In children and adolescents, can be failure to make expected weight gains
insomnia or hypersomnia
psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness or inappropriate/excessive guilt
diminished ability to think or concentrate, or indecisiveness
recurrent thoughts of death or suicide
The symptoms do not meet criteria for a mixed episode.
The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by bereavement (i.e., depressive/grief symptoms lasting less than 2 months).
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 American Psychiatric Association.)
In this chapter, we describe the characteristics and epidemiology of unipolar depressive disorders in children and adolescents, etiologic risk factors for depression onset and recurrence, and assessment and differential diagnosis of depressive disorders. We review recommended psychosocial and pharmacological treatments, and in conclusion, suggest areas for future investigation.
General Considerations
Child and adolescent depressive disorders are common, often recurrent, and generally continue into adulthood. These disorders are often familial, and are associated with additional morbidity and mortality from comorbid substance abuse and from suicide and suicidal behavior. Patients also suffer educational and later occupational underachievement as well as relationship difficulties. Therefore, early identification and treatment of these conditions are important public health issues.
The estimated prevalence of MDD is 2% in children and 4–8% in adolescents. After puberty, the risk for depression increases two- to fourfold, with 20% incidence by the age of 18 years. The gender ratio in childhood is 1:1, with an increase in the risk for depression in females after puberty, when the male/female is estimated at 1:2. This may be related to higher rates of anxiety in females, changes in estradiol and testosterone at puberty, or sociocultural issues related to female adolescent development.
It is important to differentiate childhood-onset from adolescent-onset depression. Depressive disorders in adolescence are much more likely to be recurrent into adulthood. In the context of significant family adversity, prepubertal depression is most often comorbid with behavioral problems. A less common form of childhood prepubertal depression is associated with strong familial loading for depression, high rates of anxiety, high risk for bipolar outcome, and recurrent mood disorder into adolescence and adulthood.
Early-onset depression is multifactorial, including, but not limited to, familial factors, early life events, neuroendocrine changes, and genetics. Twin studies show the importance of genetic and environmental factors, particularly in interaction. Familial risk factors for recurrent depressive disorders in youth include early-onset parental mood disorder. Non-familial depression has as risk factors parental substance-abuse disorder, parental criminality, family discord and low family cohesion. Abuse may also be related to an earlier onset of depressive symptoms, as well as many other comorbid conditions. The contribution of early adverse life events is much greater in the setting of familial genetic risk factors.
The strongest single factor for developing MDD is familial loading for the disorder. The majority of studies including twin, adoption and high-risk studies have shown a familial pattern with interaction of environmental and genetic factors. Family studies show a two- to fourfold increased risk for depression in offspring of depressed parents. Twin studies show a heritability for depression of 40–65%. Evidence from twin studies shows greater genetic concordance in adolescent-onset depression than in childhood-onset depression, suggesting that very early onset depression is more related to environmental factors.
One model of the interaction of genes and environment indicates a strong cotransmission for depression and anxiety, with heritability of greater than 60%. Genes imparting risk for anxiety may lead to youth depression by increasing sensitivity to adverse life events, another example of gene–environment interaction. This model is further supported by the association of the genetic variant of the serotonin receptor that is less functional, contributing to early-onset depression in interaction with stressful life events.
Clinical Findings
Depressive symptoms in childhood include consistent sad or depressed mood, anhedonia, change in appetite (increase or decrease), sleep disturbance, anergia, amotivation, irritability or agitation, worthlessness or guilt, poor concentration, and morbid ideation or thoughts of suicide. Children and adolescents may present with psychomotor retardation, but more often present with disabling irritability.
Children and adolescents presenting with depressive symptoms may be classified on the basis of impairment, severity, persistence of illness, and symptom profile. In the absence of a stressor leading to time-limited adjustment disorder, depression not otherwise specified (NOS) is diagnosed when full criteria for an MDD are not met. Dysthymic disorder is pervasive and chronic, lasting at least 1 year, with fewer symptoms than MDD. Dysthymia may be complicated by major depressive episodes, and is then often referred to as “double depression.” Dysthymic disorder or “minor depression,” and subsyndromal depression can be disabling, and may be precursors to MDD.
Major depression involves depressed mood, irritable mood, or anhedonia, plus four other symptoms. It is the most severe of the depressive disorders, and can be associated with psychosis. Psychosis presents as auditory hallucinations of a derogatory and mood-congruent nature, but may also include morbid visual hallucinations or delusional thinking in severe cases.
No psychological test is diagnostic of major depressive disorder. A comprehensive psychiatric diagnostic evaluation is the most useful tool to diagnose depressive disorders in children and adolescents. The Mood and Feelings Questionnaire (short-form) can be used to screen for depression and also to monitor treatment.
No laboratory studies are diagnostic of major depressive episode, however, laboratory findings are abnormal in some patients with MDD symptoms. Provocative studies of noradrenergic, hypothalamic–pituitary adrenal axis, and serotonergic systems have been found to be abnormal in depressed child and adolescent patients, but this is particularly true of patients exposed to trauma or severe life stressors.
Subclinical hypothyroidism, anemia, diabetes, and vitamin deficiencies including B12 and folate are associated with depressive symptoms. While these are more common in adults, screening laboratories including thyroid function testing, complete blood count, electrolytes, blood sugar, and B12
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