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Depression

Depression Diagnosis, Treatment and Support
 
Depression is a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and a loss of interest or pleasure in normally enjoyable activities.  Depression probably results from a genetic predisposition coupled with environmental stressors.  Major depressive disorder is a disabling condition that can affect a child’s family and school life, sleeping and eating habits, and general health.
 
Children suffering from depression may present with poor concentration, loss of pleasure in activities, and fatigue that may affect school performance and academic functioning.  They may be irritable, short-tempered and hard to please, making peer and family relationships difficult.  Feelings of worthlessness can affect self-confidence, which in turn can affect schoolwork, extracurricular activities and self-esteem.  Your child may have multiple aches and pains for which there are no identifiable medical causes (often body-aches, fatigue, headaches and stomache-aches without observable symptoms.) 
 
Some anxious and/or depressed adolescents resort to “cutting” (http://www.mayoclinic.org/diseases-conditions/self-injury/basics/definition/con-20025897) where they use a sharp instrument to make superficial wounds on their arms or legs in an effort to relieve frustration, anxiety and emotional pain.  While the act may temporarily relieve tension and stress, it is often followed by feelings of guilt, shame and a return of the emotions that triggered the behavior.  If you notice any linear cuts or circular burns on your teen’s body, particularly in varying stages of healing, make sure to bring them in for an evaluation even if the teen has a “story” for why these happened.
 
Diagnosis
 
Depression is typically diagnosed using a number of self-report and parent evaluation tools, such as the Columbia Depression Scale, the PHQ and the Children’s Global Assessment Scale (C-GAS) along with an extensive in-person interview of the parent and child   We occasionally pick up symptoms of depression on the Adolescent Screen completed by all teens at their well-child visit.  If a parent or teen requests an evaluation for possible depression, we will ask that both the parent and child fill out certain questionnaires prior to a visit, which will help the physician guide the evaluation.
 
Treatment
 
Fortunately, depression is treatable, though it may take weeks to months for the patient to return to his/her baseline.  Without treatment, depression may last months to years, puts the child at risk for suicide and substance abuse, and is likely to recur.
 
The mainstays of depression treatment are psychological counseling, sometimes coupled with medication.  The most common approach in pediatrics is to start with Cognitive Behavioral Therapy (CBT).  CBT is based on the idea that thoughts can influence behaviors and feelings, and vice versa.  Treatment targets the patient’s thoughts and behaviors to improve his/her mood.  Essential elements of CBT include increasing pleasurable activities (behavioral activation), reducing negative thoughts (cognitive restructuring), and improving assertiveness and problem-solving skills to reduce feelings of helplessness.
 
Occasionally a therapist will use Interpersonal Therapy for Adolescents (IPT-A), which presumes that interpersonal problems may cause or exacerbate depression and that depression, in turn, may exacerbate interpersonal problems.  Treatment targets a patient’s interpersonal problems to improve both interpersonal functioning as well as his/her mood.  IPT-A aims to identify interpersonal problem areas, improve interpersonal problem-solving skills and modify communication patterns.
 
Although CBT or IPT are proven therapy treatments for youth depression, they are occasionally not easily available or affordable long term, and medication is sometimes indicated and/or preferred.  Medication may be needed if the child has severe or persistent depression or has co-morbid anxiety disorders (e.g. panic, separation anxiety, social phobia, GAD or OCD).
 
Most antidepressant medications increase the levels of one or more of the monoamines — the neurotransmitters serotonin, norepinephrine and dopamine — in the synaptic cleft between neurons in the brain.. Antidepressants influence the overall balance of these three neurotransmitters within structures of the brain that regulate emotion, reactions to stress, and the physical drives of sleep, appetite, and sexuality.
 
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Currently, Selective Serotonin Reuptake Inhibitors (SSRIs) are the medication of choice for the treatment of depression and anxiety in children and adolescents.  Fluoxetine (Prozac) is the only SSRI that has FDA approval for the treatment of depression in children
and adolescents. Positive Randomized Clinical Trials (RCTs) in anxiety disorders of children and  adolescents using fluvoxamine (Luvox), and Sertraline (Zoloft) have been published and both are FDA approved for adolescent Obsessive Compulsive Disorder. Recent positive studies of citralopram (Celexa)
and sertraline (Zoloft) in adolescent depression have also been published. Other SSRIs are possibly effective. The FDA reviewed drug company treatment trials of SSRIs used with children and
adolescents for safety and efficacy because of concerns that in some children these agents may provoke extreme irritability, suicidal thinking and behavior, or other unusual symptoms.
 
It is important that parents closely supervise children and teens who are on SSRIs.  Parents should supervise administration and storage of the medication, so that it is not abused or stopped without notice.  Typically treatment is for approximately 6 months to 1 year after cessation of symptoms.  In some cases, medication may be required for a prolonged period of time.  Some children experience increased agitation, irritability, or decreased sleep when starting the medication.   Discontinuing or decreasing the dose of the SSRI may be necessary in this situation.  Once SSRIs have been in use for several weeks, rapid withdrawal will produce uncomfortable side effects ((e.g., recurrence of depression, drowsiness, nausea, lethargy, headache, dizziness).  Never stop an SSRI without guidance on weaning from a physician.
 
While SSRIs are considered generally safe and effective in children, there are side effects to be aware of.  Some common side effects of SSRI’s include the following:
 
•  Constipation
•  Diarrhea
•  Sweating
•  Sleep disturbance
•  Sexual dysfunction
•  Irritability
•  “Disinhibition” (risk-taking behaviors, increased impulsivity, or doing things that the youth might not otherwise do)
•  Agitation or jitteriness
•  Headache
•  Appetite changes
•  Rashes
 
Some other, more serious (but rare) side effects include the following:
  • Serotonin syndrome (fever, hyperthermia, restlessness, confusion, etc.)
  • Akathisia (sensation of inner restlessness resulting in constant movement)
  • Hypomania
  • Discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache) 
  • suicidal thoughts/actions
 
If your child develops a rash, becomes agitated, silly, speaks too fast, seems over-energetic, or sleeps much less, or expresses suicidal thoughts, stop the medication and call the doctor immediately.
Medication should ideally be initiated concurrent with psychotherapy, particularly if your child has severe symptoms or functional impairment, or is at risk for suicide.  If your child is at risk of suicide, or has previously attempted suicide, medication must be kept in a secure location inaccessible to the child.
 
Much of this information is borrowed and adapted from the Columbia Treatment Guidelines (2002). Depressive Disorders (Version 2). Columbia University,
Department of Child and Adolescent Psychiatry, New York, NY.
Use with
 
Depression resources:
 
NAMI family guide, “What Families Need to Know about Adolescent Depression” :www.nami.org/Template.cfm?Section=Child_and_Adolescent_Action_Center&template=/ContentManagement/ContentDisplay.cfm&ContentID=24806
 
Depressions signs/symptoms/support for parents:
www.helpguide.org/mental/depression_teen.htm
 
Depression signs/symptoms/support for teens:
http://www.helpguide.org/mental/depression_teen_teenagers.htm
 
 
Suicide prevention and support:
http://www.suicidepreventionlifeline.org
www.suicide.org/hotlines/connecticut-suicide-hotlines.html
 
On call 24/7:
 1-800-273-TALK (8255)
(800) SUICIDE (784-2433)
Southwest CT regional mental health hotline:  (203) 358-8500
 
Drug and alcohol addiction resources:
 
Alcoholics Anonymous
www.aa.org/ 
212-870-3400
 
Alanon/Alateen
www.al-anon.alateen.org
1-888-4AL-ANON
 
Narcotics Anonymous
www.na.org
818-773-9999
 
National Clearinghouse for Alcohol and Drug Information
www.health.org
1-800-729-6686