Approach

Adolescent and pre-adolescent depressive disorders are clinical diagnoses, based on a comprehensive diagnostic evaluation of history and presenting symptoms. It is crucial to make an accurate diagnosis, with input from multiple sources including, but not limited to, the child, parents, and school (teachers, counsellors).

Initial concerns about symptoms and signs may be brought to the attention of the physician by the parents, other carers, or by the child or adolescent themselves. Alternatively, the diagnosis may be made following screening. Children and adolescents with risk factors for depressive illness who are seen at primary care settings need to be screened for depressive disorder. Annual universal screening in a primary care setting is recommended for all children aged 12 years and older, even in the absence of specific risk factors, according to US-based guidance.[57] Children who come to a psychiatric facility always need to be screened for depression, because depression is highly comorbid with other psychiatric disorders.

There is no specific test for childhood depression. Hypothyroidism, anaemia, autoimmune diseases, vitamin deficiencies, and infectious mononucleosis could cause symptoms of depression. Depression risk is also increased in inflammatory bowel disease, asthma, and epilepsy, and with use of medications that are depressogenic, including corticosteroids. A baseline full blood count (FBC) with differential and thyroid function test should be performed to exclude medical causes of depression, particularly if other symptoms of these disorders are present, or if the child is at risk for these disorders.

History

Both the child and the parents should be interviewed separately. Screening should be completed by direct clinician interview, in addition to screening instruments.[57]

For adolescents in particular, interviewing them first may improve co-operation. A careful investigation of the following points is important to formulate a diagnosis:

  • The length of time for which depressive symptoms have been present

  • Potential precipitants

  • Any change of functioning.

Adolescent and pre-adolescent depression is often precipitated by the loss of loved ones (including pets), loss of peer support due to relocation, and conflicts with peers and/or parents. A careful review of the following will help to exclude differential diagnoses and formulate the treatment plan:

  • Developmental history

  • Medical history

  • Presence of comorbid psychiatric disorders, substance use or abuse

  • Family history of psychiatric illness, particularly depression and bipolar disorder.

Risk factors that are strongly associated with depression include a family history of depression, other parental psychopathology, stress or trauma, female sex, sexual minority (lesbian, gay, bisexual, transgender, and questioning) status, a personal history of other psychiatric disorders (e.g., anxiety) or a chronic medical condition, postnatal status, neighbourhood and social instability, and the use of immunosuppressive medications.

Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5): criteria for major depressive episode

To diagnose major depressive disorder (MDD), a child needs to have at least 5 of the following 9 symptoms, which indicate a significant change from his or her baseline presentation, during a same 2-week period, with at least one symptom being either depressed or irritable mood or anhedonia:[1]

  • Depressed or irritable mood

  • Decreased interest or lack of enjoyment

  • Decreased concentration or indecision

  • Insomnia or hypersomnia

  • Change of appetite or change of weight

  • Excessive fatigue

  • Feelings of worthlessness or excessive guilt

  • Recurrent thoughts of death or suicidal ideation

  • Psychomotor agitation or retardation.

In addition, these symptoms must cause significant functional impairments in school, social settings, and/or family. They are not better accounted for by a grief reaction, and are not due to a substance or to a medical illness. There should not be a history of manic or hypomanic episode.

MDD can be classified according to how many episodes have occurred.

  • MDD, single episode: the presence of 1 major depressive episode, not part of schizoaffective disorder or superimposed on a psychotic disorder; no history of a manic episode or a hypomanic episode

  • MDD, recurrent: criteria are the same as MDD, single episode, but with at least 2 major depressive episodes.

MDD is also classified according to 3 levels of severity:

  • Mild

  • Moderate

  • Severe, with or without psychotic features.

Exact features for each of these severity levels are not clearly defined. Individual physicians make a judgement of the severity of the depressive disorder, based on global functional impairment ratings and the severity and number of symptoms present. For the severe form with psychotic features, the psychotic features could be either mood-congruent or mood-incongruent, depending on whether the content of the delusions or hallucinations is consistent or inconsistent with depressive themes.

There are 9 specifiers:

  • With anxious distress

  • With mixed features

  • With catatonia

  • With melancholic features

  • With atypical features

  • With mood-congruent psychotic features

  • With mood-incongruent psychotic features

  • With peripartum onset

  • With seasonal pattern.

Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5): criteria for persistent depressive disorder (previously known as dysthymia in DSM-IV)

A child needs to have at least 3 of the following symptoms, which occur most of the day, more days than not, and for at least 1 year, and sad or irritable mood must be one of the symptoms:[1]

  • Sad or irritable mood

  • Increased or decreased appetite

  • Insomnia or hypersomnia

  • Fatigue

  • Decreased self-esteem

  • Poor concentration or indecision

  • Feelings of hopelessness.

In addition, the following criteria need to be met to make a persistent depressive disorder diagnosis:

  • During the year, the child has never been without sad or irritable mood and 2 other symptoms for >2 months at a time

  • These symptoms cause significant distress or impairment in multiple areas of functioning

  • There has never been a manic or hypomanic episode, or symptoms meeting the criteria for cyclothymic disorder

  • The symptoms are not caused by a substance medical condition

  • The symptoms are not better explained by schizoaffective disorder or other psychotic disorder.

Presenting symptoms

Both the child and the parents should be asked about specific depressive symptoms, based on the DSM-5 diagnostic criteria. Common symptoms include sad and/or irritable mood, decreased concentration and school performance, diminished enjoyment of activities, fatigue, a change of appetite, difficulties with sleep, low self-esteem, hopelessness, excessive guilt, and suicidal thoughts. A common sign in a depressed child is social withdrawal or changes in social relationships. Although not a DSM-5 diagnostic criterion, excessive somatic complaints may also be common, especially in the younger depressed child. Both self- and parent-rating scales and clinician-rating scales may be helpful in eliciting symptoms. These scales can be used throughout treatment to more effectively monitor improvement or worsening of symptoms.

In addition, clinicians need to review the child for manic and hypomanic symptoms such as elevated mood, decreased need for sleep, and grandiosity, as well reviewing the family history, to exclude the potential possibility of a bipolar disorder. Adults with bipolar disorder often report that their initial symptoms were of a depressive disorder. All children and adolescents presenting with depression should be screened for manic symptoms.

It is important to exclude a normal bereavement response as the cause of the presentation. Although symptoms of depression may increase the risk of children and young people self-medicating with various substances, it is also important to exclude the possibility that the presentation is a direct effect of a substance.

Clinicians should also assess for the presence of the following common comorbid mental health conditions, which may affect the diagnosis and management of the depressive disorder:[57]

  • Anxiety disorders

  • Attention-deficit hyperactivity disorder

  • Physical abuse and trauma.

A safety assessment, including for suicidality, should be completed by the clinician.[57]

Impairment

An assessment of functional impairment resulting from the current depressive symptoms needs to be included. Depressive symptoms need to cause significant impairment in one or more areas of functioning (e.g., school, home, social settings) to meet DSM-5 criteria for MDD or persistent depressive disorder (dysthymia). Information regarding the severity of depressive symptoms and functioning impairment will guide the treatment approach.

Depression frequently co-occurs with substance abuse during adolescence. In addition, some substances are known to cause depressive symptoms.[51][52] According to the DSM-5 diagnostic criteria, a diagnosis of MDD or persistent depressive disorder (dysthymia) should not be made if the symptoms are thought to be related to the direct effect of a substance or a medication.

Examination

There are no specific physical examination findings for depression, but a physical examination is helpful in excluding medical causes of depression. Various medical causes include:

  • Infectious mononucleosis

  • Vitamin deficiencies

  • Anaemia

  • Substance abuse

  • Thyroid dysfunction.

In many cases, symptoms of these conditions may not be easily differentiated from symptoms of depression (e.g., lack of energy, poor appetite, hypersomnia), which should be kept in mind during the physical examination and subsequent work-up. With increasing rates of juvenile obesity, which in itself can be comorbid with depression, there is an increase of micronutrient deficiency (e.g., vitamin B12, iron, folate, vitamin D).[58]

A mental status examination of a child's attention, affect, speech, motor activity, thought process, thought content, suicidal and homicidal thoughts, hallucinations, delusions, insight, and judgement will help to determine an appropriate level of care and treatment approach. Psychomotor agitation or retardation may be noted.

Investigations

A work-up for reversible causes of depression should be considered standard practice. The most common baseline tests include:

  • FBC (with differential)

  • Serum thyroid-stimulating hormone and free thyroxine

  • Urine drug screen

  • Screening for vitamin deficiencies, especially B12, folate, and vitamin D.

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