Depression in children

Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR): classification of depressive disorders​[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.​

Categorises depressive disorders in children into the following categories: major depressive disorder (MDD), persistent depressive disorder, disruptive mood dysregulation disorder (DMDD), 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.

DSM-5-TR: criteria for major depressive disorder​[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.​

To diagnose major depressive disorder, 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:

• 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, recurrent suicidal ideation without a specific plan, a specific suicide plan, or a suicide attempt.

• 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 episodes.

The International Classification of Diseases, 11th revision (ICD-11) is overall consistent with the DSM-5-TR criteria. The ICD-11 threshold for ‘depressive episode’ is the same: at least five symptoms, but it is out of a list of ten instead of nine in the DSM-5-TR. The additional symptom is ‘hopelessness'.[2]World Health Organization. ICD-11 for mortality and morbidity statistics (ICD-11 MMS). Feb 2022 [internet publication]. https://icd.who.int/browse11/l-m/en

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. However, if admission to hospital is required for treatment of MDD, it is classified as severe. 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.

DSM-5-TR: criteria for persistent depressive disorder​[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.​

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:

• Sad or irritable mood

• Increased or decreased appetite

• Insomnia or hypersomnia

• Low energy or fatigue

• Low 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 or medical condition

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