Approach
Adolescent and preadolescent 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, counselors).
Symptoms and signs are identified by parents or teachers, or less commonly self-reported by the child or adolescent. The pathway to the physician is usually via the parent, although it may be on the recommendation of the school. Alternatively, the diagnosis may be made following screening. The author’s view is that children and adolescents with risk factors for depressive illness who are seen at primary care settings should be screened for depressive disorder. Screening of children and adolescents with risk factors for major depressive disorder is also recommended in the emergency department setting.[63] Annual universal screening in a primary care setting is recommended for all children ages 12 years and older, even in the absence of specific risk factors, according to US-based guidance.[64] This approach is endorsed by the US Preventive Services Task Force (USPSTF).[65] At present, the USPSTF does not recommend screening for depression in children ages 11 years or younger, based on insufficient evidence of net benefit. However, note that in children in this age group, early identification can facilitate early intervention.[66] Children who come into contact with psychiatric services always need to be screened for depression, because depression is highly comorbid with other psychiatric disorders.[67] Depression rating scales may support initial diagnosis of depression, and may also facilitate measurement of response to treatment over time ("measurement-based treatment").[66] See "Screening" for details on recommended screening instruments (depression rating scales) in different age groups.
A safety assessment, including review of thoughts of suicide and self-harm, should be completed by the clinician at the first clinical encounter, and at all subsequent encounters.[64][68] In adolescents, asking about suicidality should typically take place in a confidential manner, without caregivers present, given that young people may be reluctant to report suicidal ideation in the company of caregivers.[68] The American Academy of Pediatrics (AAP) recommends the use of a brief suicide safety assessment (BSSA) for all patients disclosing suicidal ideation, in order to further explore their personal risk and protective factors. Note that the BSSA is different from the initial screening tool, which simply identifies risk.[69] It is imperative to ask about access to lethal means (firearms, medications, illicit substances, knives, ropes) when suicidal ideation or a plan is disclosed, followed by risk-tailored counseling and mitigation.[68][70] A positive screening result for suicidal ideation should be followed safety planning, an intervention that encompasses helping the patient identify their risk factors for suicidal ideation as well as a series of supports that they can draw on to reduce their risk of self-harm. Children and adolescents who are depressed with severe suicidality without being able to maintain safety, or with significant psychosis, require urgent referral to the emergency department.
See: Suicide risk mitigation.
Other safety risks to explore include risk-taking behavior and impulsivity. Clinicians should explore exposure to childhood adversities; if there is suspicion of abuse or neglect, collateral history may be needed, plus referral to local childhood welfare authorities according to the location of practice.[66] Two basic questions may help guide a safeguarding assessment: (1) Is the patient at current risk? (2) Are the patient and family able to adhere to recommendations regarding supervision, safeguarding, and follow-up care? The answers to these questions will help to guide the appropriate level and intensity of care.[66]
There is no specific test for childhood depression. Hypothyroidism, anemia, 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 complete blood count (CBC) with differential and thyroid function tests 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 parent/guardian should be interviewed, either separately or together or both, as developmentally and clinically indicated.[66] For older children and for adolescents, it is good practice to see them on their own for at least part of the consultation, and this may encourage young people to describe symptoms that they are reluctant to mention in the presence of an accompanying adult. Screening should be completed by direct clinician interview, in addition to screening instruments.[64] A collateral history (e.g., from teachers, primary care, child agency workers, other family members etc, as appropriate, and ensuring that the appropriate consent has been obtained) may be beneficial.[66]
For adolescents in particular, interviewing them first may improve engagement. 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 preadolescent 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 exclude differential diagnoses and formulate the treatment plan:
Developmental history
Medical history
Presence of comorbid psychiatric disorders, substance use or misuse
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 conduct disorder) or a chronic medical condition, postpartum status, neighborhood and social instability, and the use of immunosuppressive medications.
Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR): criteria for major depressive disorder
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, 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]
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 judgment 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.
Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR): criteria for persistent depressive disorder
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
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.
Presenting symptoms
Both the child and the parents should be asked about specific depressive symptoms, based on the DSM-5-TR diagnostic criteria. Core symptoms are sad and/or irritable mood and diminished enjoyment of activities/anhedonia. Associated symptoms include decreased concentration and school performance, 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, as most anxious children remain socially motivated. Although not a DSM-5-TR 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 and 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.
Sometimes, depressed children will also experience hallucinations or delusional thoughts about worthlessness or guilt as part of the depressed mood syndrome. While this does not mean the child has a psychotic disorder, it is important to note the presence of these factors, ensure they improve with treatment for depression, and consider this when developing a treatment plan.
Depression frequently co-occurs with substance use disorders during adolescence. In addition, some substances are known to cause depressive symptoms.[57][58] According to the DSM-5-TR diagnostic criteria, a diagnosis of MDD or persistent depressive disorder should not be made if the symptoms are thought to be related to the direct effect of a substance or a medication.
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:[64]
Anxiety disorders
Attention-deficit hyperactivity disorder
Autism spectrum disorder
Physical abuse and trauma.
Impairment
An assessment of functional impairment resulting from the current depressive symptoms needs to be included. Depressive symptoms need to cause significant impairment in 1 or more areas of functioning (e.g., school, home, social settings) to meet DSM-5-TR criteria for MDD or persistent depressive disorder. Information regarding the severity of depressive symptoms and functioning impairment will guide the treatment approach.
Examination
There are no specific physical examination findings for depression, but a physical exam is helpful in excluding medical causes of depression. Various medical causes include:
Infectious mononucleosis
Vitamin deficiencies
Anemia
Substance use disorder
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 exam and subsequent workup. 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).[71]
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 judgment will help determine an appropriate level of care and treatment approach. Psychomotor agitation or retardation may be noted.
Investigations
A workup for reversible causes of depression should be considered standard practice. The most common baseline tests include:
CBC (with differential)
Serum thyroid-stimulating hormone and free thyroxine
Urine drug screen
Screening for vitamin deficiencies, especially B12, folate, and vitamin D.
Use of this content is subject to our disclaimer