Major depressive disorder is one of the most common disorders among adolescents, with prevalence estimates as high as 20%-24%. Although it is less common in younger children, it nonetheless occurs and might signal a more severe lifetime course.
Often, depressed children and adolescents respond well to treatment, which might include pharmacologic interventions and psychotherapy.
However, a core group of pediatric patients presents with severe symptoms, including suicidality–the third leading cause of death beginning at age 15.
Moreover, relapse occurs in 34%-50% of adolescents, often early, and even after successful resolution of symptoms, according to Dr. Graham Emslie, professor of child and adolescent psychiatry at the University of Texas, Dallas, who has extensively studied adolescent depression. Relapse rates of as high as 70% have been reported over 6–7 years.
Initially, clinicians should be alert to potential risk factors that could point to a severe clinical course, including parental depression and “high genetic loading,” such as a family history of bipolar disorder, said Dr. Emslie in an interview.
Depression, of course, must be assessed developmentally, with melancholic depression less common in younger children.
Withdrawal, irritability, fears/social anxiety, destructive behavior, somatic complaints, and poor social or academic functioning are considered possible signs of depression in early to middle childhood, according to Bright Futures in Practice, a mental health guide for pediatricians sponsored by the Health Resources and Services Administration and the National Center for Education in Maternal and Child Health at Georgetown University in Washington.
In practice, severe and/or treatment-resistant depression in young children might be marked by psychotic features and might eventually develop into bipolar disorder, said Dr. David Brent, professor of psychiatry, pediatrics, and epidemiology at the University of Pittsburgh and the cofounder and director of Services for Teens at Risk (STAR), a suicide prevention program funded by the Commonwealth of Pennsylvania.
Severe depression in adolescents, “as opposed to severe problems–family chaos, substance abuse, and so on–is characterized by high scores on severity scales … severe suicidal thought without the ability to develop a safety plan or nonresponse to adequate treatment,” said Dr. Emslie in an interview.
The scales Dr. Emslie prefers are the Quick Inventory of Depressive Symptomatology (16 items) or the Center for Epidemiologic Studies Depression Scale (20 items).
Other factors common to difficult-to-treat adolescent patients include comorbid psychiatric diagnoses, longstanding symptoms of depression, and substance abuse issues, Dr. Brent noted.
Both Dr. Emslie and Dr. Brent have been investigators in trials of various antidepressants for the primary treatment of adolescent depression and relapse prevention.
Current Food and Drug Administration–approved treatments for depression include fluoxetine for children and adolescents aged 8–17 years and escitalopram for adolescents aged 12–17.
Both experts participated in the recently published TORDIA study (Treatment of SSRI-resistant Depression in Adolescents), in which 334 adolescents who had failed one trial with an SSRI were randomly assigned to a switch to another SSRI or venlafaxine, with or without cognitive-behavioral therapy.
Systematic (weekly) monitoring rather than spontaneous reports increased detection of suicidal self-injury (20.8% vs. 8.8%), and nonsuicidal self-injury (17.6% vs. 2.2%). The median time to a suicidal event was just 3 weeks into the trial, with more events reported among youth who had high baseline suicidal ideation, family conflict, and drug and alcohol use (Am. J. Psychiatry 2009;166:418-26).
Nonsuicidal self-injury also was an early event, with a median time to occurrence of 2 weeks. A previous history of nonsuicidal self-injury was an independent risk factor for a repeated, similar event.
In the paper reporting TORDIA results, and in interviews, Dr. Brent and Dr. Emslie emphasized early and aggressive monitoring of adolescents with risk factors, especially family conflict, suicidal ideation, and drug use.
Children and adolescents who are embroiled in family or school conflict, concerns about abuse and/or sexual identity, parental depression, or substance abuse likely need combination treatment that includes psychotherapy, Dr. Brent said.
Although polypharmacy is common, it has not been studied in adolescents.
“We prefer not to resort to it,” Dr. Brent said. “We do it when we have a patient who has shown some response to a medication but has not completely remitted, and we have pushed the dose as high as makes sense.”
Most commonly, that index drug is an SSRI, he said.
“Agents that are commonly used for augmentation are bupropion, especially if the patient has fatigue or symptoms of [attention-deficit/hyperactive disorder], thyroxine, lithium, and antipsychotics.”
All of these agents have been studied in adults, but none have been studied in adolescents, Dr. Brent emphasized.
In clinical practice, an antipsychotic might need to be the initial drug used to treat psychotic depression, prescribed either alone or in combination with an antidepressant, Dr. Emslie said.