DEPRESSION

in Children and Adolescents Dr Wendy Vogel. Child & Adolescent Psychiatrist,

Division of Child and Adolescent Psychiatry,

Red Cross War Memorial Children’s Hospital and University of Cape Town.

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DEPRESSION

“Depressive disorders are often familial

recurrent illnesses associated with

increased psychosocial morbidity and

mortality. Early identification and

treatment may reduce the

impact…Evidence supported treatment

interventions have emerged…” J.Am Acad of Child adolesc. Psychiatry 46:11 Nov 2007

Depression refers to MDD and Dysthymia

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EPIDEMIOLOGY

1-2 % in children (aged 6-12 years)

2-5% in adolescents (aged 13-18 years)

during childhood m:f ratio 1:1

during adolescence m:f ratio 1:2

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Environmental factors

Family conflict

Bullying

Abuse

Poor support

Increased evidence of stressful life event in 12 months prior to onset

Death of a caregiver

Divorce

Birth of a sibling

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Environmental factors

Acquired physical illness or injury

Developmental challenges

Co-morbidity (anxiety,ADHD,ASD)

Medical conditions

NOTE: The effect of these stressors also

depends on the child’s negative

attributional styles for interpreting and

coping with stress, support and genetic

factors

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CLINICAL PRESENTATION:

2/52 changed mood

Depressed/irritable

Loss of interest

Changes in appetite

Weight changes

Sleep changes

Activity levels change

Concentration decreases

Energy level changes

Self-esteem is low

Motivation poor

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CLINICAL PRESENTATION:

Wishing to be dead

Suicidal attempts or ideation

Exaggerated guilt

Feeling hopeless

Clinical picture similar to adults but

differences attributed to child’s physical,

emotional, cognitive and social development

Dysthymia: chronic condition lasting for a year

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Clinical features: pre-school

under 6 years

Apathy

Food refusal

Miserable

Crying

Rocking

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Clinical features: middle school

6-12 years

Somatization

Low self- worth

Poor school

performance

Anxiety

Irritable, Bored,

Sad,

Angry

Sleep & Appetite

changes

A.D.H.D-like

Apathy

Withdrawn

Temper outbursts

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Clinical features:

adolescents Melancholia

Conduct problems

Suicide attempts

Functional impairments

Atypical presentation

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CO-MORBIDITY

40 – 90% have other psychiatric disorders

20 – 50% have two or more co-morbidities

Dysthymia: 30-80%

ASD

Anxiety: 30-80%

Disruptive Disorders: 10 – 80%

Substance Use disorders: (20-30%)

These may predate MDD

Risk of early pregnancy

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DEPRESSED CHILDREN

MULTIPLE PROBLEMS

Educational failure

Impaired psychosocial function

Co-morbid disorders

High family psychopathology

Risk of suicide (hx of attempts, co-morbid

conditions, impulsivity and aggression, lethal weapons,

exposure to negative events)

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ASSESSMENT:

• Interview parents & child & family

• Collateral (school, others)

• Psychiatric interview with M.S.E.

• Physical exam: (TFT)

• Review medical & psychiatric hx

• Family medical & psychiatric hx

• Rating scales

• Psychological assessment

• Assess severity and impairment

• Assess safety (and safety plan)

• Assess required level of care

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CONSIDER:

Potential co-morbidities

Social, educational and family context

Quality of relationships

Social network for positive or negative impact

Always ask about substance use, bullying, abuse, self harm, suicidal

ideation

Opportunity for privacy/confidentiality

Consider cultural and family values

Consent

Child protection

Consider the parents’ mental health

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TREATMENT:

Therapeutic Alliance/rapport/confidentiality

Psycho-education. Give written information.

Give advice about self help groups , leaflets

Evidence based research on Rx is sparse

Treat co-morbid diagnosis, social & educational problems, NB bullying

Offer CBT , IPT or short-term family Rx

Consider parents’ psychopathology and refer

Use CDI or MFQ to monitor progress

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Mood and Feelings Questionnaire--

1. I felt awful or unhappy.

2. I didn't enjoy anything at all.

3. I was less hungry than usual.

4. I ate more than usual.

5. I felt too tired I just sat around and did nothing.

6. I was moving and walking more slowly than usual

7. I was very restless.

8. I felt I was no good anymore.

9. I blamed myself for things that weren't my fault.

10. It was hard for me to make up my mind.

11. I felt grumpy and upset with my parents.

TREATMENT

Medication plus psychotherapy is best

combination (although mixed evidence)

AACAP vs NICE guidelines

Opinion is divided as to whether to start

with psychotherapy first

Mild depression may respond to

supportive psychotherapy only. Period of

watchful waiting. Discuss lifestyle

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TREATMENT

TADS Study (March et al Arch Gen Psych Vol 64 (No 10) Oct 2007)

(March & Vitiello Am J Psychiatry 166: Oct 2009)

ADAPT Study (Goodyer et al, Health Technol Assess 2008;12 1-60)

TORDIA Study (Brent et al, JAMA 2008;299(8):901-913)

NICE GUIDELINES/AACAP Practice

parameters

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TADS STUDY

TADS matters : mod to severe range of illness

Combined treatment (CBT plus fluoxetine) significantly accelerates benefits (at 12 weeks)

Treating patients longer makes a big difference in medical benefits (at 36 weeks)

Need 6-9 months treatment

Adding CBT to Fluoxetine minimises suicidal ideation and Rx emergent suicidal events

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TADS STUDY

Longer term treatment provides

sustained benefit once treatment is

discontinued

Combined treatment is cost effective in

the long run

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ADAPT Study

Brief (2 week) psycho educational

intervention may be effective in a

proportion of pts with moderate to

severe depression

SSRI (Fluoxetine) together with active

clinical care (ACC) is treatment of choice

if non responsive

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ADAPT Study

For non responsive adolescents, the

addition of CBT to Fluoxetine plus active

clinical care

does not improve outcome or confer

protective effects against adverse events.

SSRIs ( fluoxetine) are not likely to result

in harmful effects

After 7 months of active Rx 10% will

have no response ie Rx resistent

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ADAPT Study

No evidence of protective effect of CBT

on suicidality

Fluoxetine plus Active clinical care is

important not fluoxetine alone

How did TADS respond?

ADAPT : sicker pts, ACC good, CBT not.

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TORDIA STUDY

• MDD non responsive after 2 months on an SSRI were switched to a second DIFFERENT SSRI, or venlafaxine or either arm plus CBT.

• Combination medication plus CBT was superior.

• No difference between second SSRI and venlafaxine except for CVS side effects so they recommended changing to second SSRI and CBT

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SIDE EFFECTS

Common side effects:

Headaches

GI/Stomachaches/nausea

diarrhea

Sedation/insomnia

Sweating

Sexual side effects

Tremor

Diastolic hypertension

Uncommon side effects:

Activation

Bipolar switching

Suicidality

Serotonin syndrome

Bleeding

NICE GUIDELINES/AACAP

MILD DEPRESSION

PSYCHO-EDUCATION: written and web

• 2 week period of watchful waiting (up to 4/52)

• If continues with no suicidal ideation or co-morbidity offer psychological therapies for 2-3 months

Individual supportive psychotherapy

Group CBT

Guided self help

Family involvement //+- role of school

DONOT use anti depressants

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NICE GUIDELINES/AACAP

MODERATE TO SEVERE DEPRESSION

CBT/IPT/Family Therapy for ? 3 months

If no response look at additional factors (family discord

etc)

MEDICATION

Fluoxetine for 12 to 18 year olds

Cautiously consider Fluoxetine for 5-11 year olds

(evidence not established)

Start low and go slow

Adequate doses for long periods

If unresponsive, family Rx or individual Rx (30)

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INFORMANT

ALWAYS check outcomes with child and

adolescent

Family /caregiver feedback

School feedback

NB CONFIDENTIALITY ISSUES

Note most studies are with

adolescents..very few with children..so

adapt CBT/IPT/psychodynamic and family

Rx

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ABC of CBT

Affect identification and regulation

Behaviour activation

Cognitive restructuring

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AFFECT IDENTIFICATION

Psychoeducation about feelings and

depression

Co-existing feelings

Linking feelings to events

Hierarchy of feelings/ events

Mood thermometer

Triggers for strong negative affect

Patterns for reacting to negative affect

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AFFECT REGULATION TOOLS

Relaxation exercises

Take a deep breath

Time out Chill

Distraction

Talk about feelings

Diary

Ask for help

Imagery

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Behaviour activation

Pleasant activity scheduling

In vivo exercises ( using imagery)

Pre and post mood check

Positive self talk

Externalise distressing thoughts

Concretise the relationship between thoughts and mood

Thinking outside the box

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IMAGERY

INTERPERSONAL THERAPY (IPT)

IPT is a brief time limited Rx based on the premise that depression occurs in the context of relationships regardless of origins in biology or genetics. The IPT model identifies 4 areas of relationship difficulties:

Grief

Conflict in significant relationships

Difficulties adapting to changes in relationships or life circumstances

Difficulties from social isolation

12-16 week treatment

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PSYCHODYNAMIC

PSYCHOTHERAPY

Case based literature and clinical experience suggesting that psychodynamic therapy can address a broad range of co-morbidities..need more rigorous studies

Most cases in clinical practice have multiple factors requiring multi-modal treatment approach with a combination of CBT,IPT, individual psychodynamic, family therapy, school interventions and medication.

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PHASES OF Rx

Acute: Rx if no response to active monitoring for 6 to 12 weeks aim for remission

Continuation: All who have responded to Rx, continue Rx for 6 to 9 months aim to consolidate remission & prevent relapse

Maintenance: YP who are at high risk of recurrence (family hx MDD, multiple episodes, severe and complicated MDD) for 1- 2 years; aim to prevent recurrence.

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TIDY project

Consider stressors

Consider seeing the young person alone

Ask the transitional question

General psychiatric screening questions

Screen for depression (ask core

symptoms)

To diagnose depression

Impairment

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TIDY PROJECT

TREATING DEPRESSION After making a diagnosis

Give feedback

Name it

Describe it ie link symptoms

Link to known stressors

Give information about depression

Give leaflet

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TIDY PROJECT

TREATING DEPRESSION • Promote coping strategies

• Mobilise help

• Identify confidante

• Activity scheduling with self re-enforcement

• Give positive re-enforcement

• Reminder: It is usually self-limiting

• Invite back

• Need for referral

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CHALLENGES

Time

Lack of therapists

Self train

Nurse practitioners

School support staff

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DEPRESSED PARENTS

Role of depressed mother

• PND has negative effect on caregiving

which affected language development

(greater risk in lower se groups)

Role of depressed father

• Children whose fathers were chronically

depressed were at greater risk of

emotional & behavioural problems • Alan Stein

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SELF HELP GROUPS

South African Depression and Anxiety

Group

Gardens: 0824441952

Athlone:0798149634

BOOKS

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DCAP REFERRAL

All children under 13 years:

All adolescents over 13 years:

Non responsive to Rx

Actively suicidal with recurrent risk

Manic episodes

Psychosis

SAD

Family hx of BMD/Psychosis

Co-morbid psychiatric conditions

Side effects ( agitation/suicidality) from SSRI

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DCAP REFERRAL

Division of Child and Adolescent Psychiatry

Red Cross War Memorial Children’s Hospital &

UCT

Referral form

46 Sawkins Road, Rondebosch 7700

Tel. (021) 685 4103 Fax (021) 685 4107

Tel. (021) 685 5116 Fax (021) 689 1343

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Where is further information available?

NICE guideline:

◦ www.nice.org.uk/cg028niceguideline Information for the public

◦ www.nice.org.uk/cg028publicinfo

◦ Practice Parameters for the Assessment and

treatment of Children and Adolescents with

Depressive Disorders. J.Am.Acad. Child and

Adolesc. Psychiatry 46:11 Nov 2007.S

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THANK YOU for your attention!

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CASE STUDY:

6 year old boy

Catatonic

Depressed mood

Children’s Home

Mother in jail

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CASE STUDY:

9 year old boy

Referred for ADHD

Irritable ,disruptive in class

Poor sleeper

Apathy and lethargic

FAMILY HISTORY

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