Childhood and Adolescent (Pediatric) Depression

Childhood and Adolescent Depression is a subtype of depression characterized by low mood, anxiety, and irritability in children and youth.

• The prevalence of major depressive disorder among adolescents was reported to be about 15%.^[1]

• In adolescents with comorbid obessive-compulsive disorder, there are poorer short-term outcomes, regardless of the modality of treatment used.^[2][3]

• About 60% of adolescents with MDD have at least 1 comorbid psychiatric diagnosis.
  • The most common are anxiety disorders, attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, substance use disorders, eating disorders, learning disorders and somatic disorders.^[4]

• Genetic and environmental factors can both interact with each other to increase the risk or conversely reduce the risk of depression in children and adolescents.
• A family history of depression is associated with an up to 5 times increased risk for depression among older children.^[5]

• The diagnostic criteria for pediatric major depressive disorder and persistent depressive disorder uses the same criteria as adults in the DSM-5.
• However, children and adolescents may be more likely to present with irritability and mood lability, while adults may have more low mood, somatic concerns and social withdrawal.^[6]
  • Depression in the pediatric population may also be associated with atypical features such as hypersomnia and increased appetite.
  • Compared with younger children, adolescents are less likely to present with anxiety, somatic symptoms, psychomotor agitation and hallucinations.

• Lifestyle interventions are recommended for mild-to-moderate MDD and include strategies to improve physical activity, dietary patterns and sleep.
  • Poor lifestyle factors are associated with increased depressive symptoms among children and adolescents.^[7]

• In adult major depressive disorder, less sugar-sweetened drinks, reduced processed foods and meats, and higher vegetable, fruit and legume intake is associated with lower depressive symptoms.^[8]
• Light therapy may have a positive effect, especially in seasonal depression.^[9]

• Cognitive behavioural therapy (CBT) is the psychotherapy with the best evidence for efficacy in the treatment of adolescent depression and is the recommended first-line treatment.

• The most recent study by the Youth Depression Alleviation–Combined Treatment (YoDA-C) found that there was no benefit to adding fluoxetine to cognitive behavioural therapy.^[12]
  • Importantly, in contrast to the older Treatment for Adolescents With Depression Study (TADS) study, conducted between 2000 and 2003, the newer YoDA-C study actually implemented a placebo pill in the comparison group.^[13]

• Since children have an increased rate of drug metabolism, BID dosing at lower dosages is recommended for all SSRIs except fluoxetine to minimize the risk of daily withdrawal symptoms.

• One of the most controversial aspects of using antidepressant medications in the pediatric population is the association with increased risk of suicidal behaviour. It is important to note that Health Canada has not approved any antidepressant for use in youth, and the FDA has only approved fluoxetine in the treatment of depression.^[14]
  • In 2003, the FDA issued a black-box warning because a meta-analysis found a 1.5 to 2-fold increase in increased suicidal thoughts/behaviours (although there was no increased incidence of suicide deaths).
• Similarly, observational studies have found an increased risk for suicidal acts including suicide attempts. These findings are opposite of what is seen in other age groups (e.g. - geriatric and older adults) where SSRI use actually shows a decrease in suicidality.
  • Thus, it is important to be vigilant about the use of antidepressants in young adults and the pediatric population and monitor for suicidal behaviours or thoughts.