Depression in children is characterised by sad or irritable mood, anhedonia, decreased capacity to have fun, decreased self-esteem, sleep disturbance, social withdrawal or impaired social relationships, and impaired school performance.
At-risk children should be screened for depression. It is crucial to make an accurate diagnosis, based on a comprehensive assessment and review of the history, with input from multiple sources.
The safety of the child and others, and the duration and severity of depression, need to be evaluated carefully to help determine the appropriate level of care and treatment modality. Treatment is typically with active monitoring, specific psychotherapies, antidepressants, or a combination of these therapies.
There is an increased risk for school disengagement, substance use disorders, suicide attempts, and completed suicide. Suicidality needs to be assessed at each healthcare encounter.
Following recovery, relapse or recurrence rate is high in the absence of continuation treatment.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorises depressive disorders in children into the following categories: major depressive disorder (MDD), persistent depressive disorder (dysthymia), disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder. This topic focuses on MDD and persistent depressive disorder (dysthymia). MDD in children is a more severe form of depressive disorder, and is characterised by at least 5 depressive symptoms, with 3 levels of severity: mild, moderate, and severe. Persistent depressive disorder is a more chronic form of depressive disorder, which is characterised by a chronic sad or irritable mood, lasting for at least 1 year, with 2 or more additional depressive symptoms.
History and exam
Key diagnostic factors
- presence of risk factors
- sad and/or irritable mood
- decreased interest or lack of enjoyment
- significant functional impairment
- no evidence of a manic or hypomanic episode
- no history of recent bereavement
Other diagnostic factors
- decreased concentration or indecision
- insomnia or hypersomnia
- change of appetite or weight
- excessive fatigue
- feelings of worthlessness or excessive guilt
- feelings of hopelessness
- psychomotor agitation or retardation
- somatic complaints
- social withdrawal or change of friends
- recurrent thoughts of death or suicidal ideation and self-harm
- increased substance use
- positive family history of depression
- other parental psychopathology
- personal history of other psychiatric disorders (e.g., anxiety)
- stress or trauma
- female sex
- sexual minority status
- personal history of chronic medical illness
- postnatal status
- neighbourhood and social instability
- immunosuppressive medications (e.g., corticosteroids, interferon)
- substance use/misuse
1st investigations to order
- clinical diagnosis
Investigations to consider
- serum thyroid-stimulating hormone (TSH) and free thyroxine (T4)
- full blood count with differential
- urine drug screen
- urine pregnancy test
- serum B12 and folate
- vitamin D level
at risk of self-harm
moderate or severe
following stabilisation of acute symptoms
Philip Hazell, BMedSc, MBChB, PhD, FRANZCP, Cert Accred Child Psychiatry (RANZCP)
Conjoint Professor of Child and Adolescent Psychiatry
Specialty of Psychiatry, School of Medicine
University of Sydney
PH declares that he has no competing interests.
Khrista Boylan, MD, PhD, FRCPC
Psychiatry and Behavioural Neurosciences
KB declares that she has no competing interests.
Professor Philip Hazell and Dr Khrista Boylan would like to gratefully acknowledge Dr Lisa Pan, Dr David A. Brent, Dr Rongrong Tao, Dr Graham Emslie, and Dr Taryn Mayes, the previous contributors to this topic.
LP declares that she has no competing interests. DAB receives royalties from Guilford Press; has received or will receive royalties from the electronic self-rated version of the C-SSRS from ERT, Inc; is on the editorial board of UpToDate; is a reviewer for Healthwise; and is on the board of the Klingenstein Foundation. RT is an author of a number of references cited in this topic. GE has received research funds from BioMarin, Eli Lilly, Forest Laboratories, GlaxoSmithKline, and Somerset; has served as a consultant for Biobehavioral Diagnostic Company, Bristol-Myers Squibb, Eli Lilly, Forest Laboratories, GlaxoSmithKline, INC Research Inc., Lundbeck, Pfizer Inc., Seaside Therapeutics, Shire Pharmaceuticals, Valeant, Validus Pharmaceuticals, and Wyeth Ayerst; and has been on the speaker's bureau for Forest Laboratories. TM is an author of a number of references cited in this topic.
Richa Bhatia, MD
Director of Psychiatry
Santa Rosa Community Health
RB declares that he has no competing interests.
Paramala J. Santosh, MBBS, DipNB (Psych), MRCPsych, MD
Honorary Senior Lecturer
Institute of Child Health and Institute of Psychiatry
Consultant in Child and Adolescent Neuropsychiatry and Psychopharmacology
Head of Centre for Interventional Paediatric Psychopharmacology
Department of Child & Adolescent Mental Health
Great Ormond Street Hospital for Children
PJS declares that he has no competing interests.
Pieter Joost van Wattum, MD, MA
Assistant Clinical Professor of Child Psychiatry
Yale School of Medicine
Medical Director of Psychiatry
Clifford W. Beers Guidance Clinic
PJvW declares that he has no competing interests.
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