Depression in children

Last reviewed: 6 Sep 2022

Last updated: 09 Aug 2022

Depression in children is characterized 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.

Definition

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) categorizes depressive disorders into the following categories: major depressive disorder (MDD), persistent depressive disorder, 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.[1] This topic focuses on MDD and persistent depressive disorder. MDD in children is a more severe form of depressive disorder, and is characterized 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 characterized 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

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

More key diagnostic factors

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

Other diagnostic factors

Risk factors

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
postpartum status
neighborhood and social instability
immunosuppressive medications (e.g., corticosteroids, interferon)
substance use/misuse

More risk factors

Diagnostic investigations

1st investigations to order

clinical diagnosis

More 1st investigations to order

Investigations to consider

serum thyroid-stimulating hormone (TSH) and free thyroxine (T4)
complete blood count with differential
urine drug screen
urine pregnancy test
serum B12 and folate
vitamin D level

More investigations to consider

Treatment algorithm

INITIAL

at risk of self-harm

ACUTE

mild

moderate or severe

ONGOING

following stabilization of acute symptoms

Contributors

Authors

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

Sydney

Australia

Disclosures

PH declares that he has no competing interests.

Khrista Boylan, MD, PhD, FRCPC

Associate Professor

Psychiatry and Behavioural Neurosciences

McMaster University

Hamilton

Canada

Disclosures

KB declares that she has no competing interests.

Acknowledgements

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.

Disclosures

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.

Peer reviewers

Richa Bhatia, MD

Director of Psychiatry

Santa Rosa Community Health

Disclosures

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

London

Disclosures

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

New Haven

Disclosures

PJvW declares that he has no competing interests.

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Guidelines
- Depression in children and young people: identification and management
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Patient leaflets
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Depression in children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

at risk of self-harm

mild

moderate or severe

following stabilization of acute symptoms

Contributors

Authors

Philip Hazell, BMedSc, MBChB, PhD, FRANZCP, Cert Accred Child Psychiatry (RANZCP)

Disclosures

Khrista Boylan, MD, PhD, FRCPC

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Richa Bhatia, MD

Disclosures

Paramala J. Santosh, MBBS, DipNB (Psych), MRCPsych, MD

Disclosures

Pieter Joost van Wattum, MD, MA

Disclosures

Differentials

Guidelines

Patient leaflets

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