Evidence-Based Reviews

How to lower suicide risk in depressed children and adolescents

Current Psychiatry. 2012 May;11(5):21-32

To determine if hospitalization is necessary, assess patients’ risk factors, attitude toward treatment

References

1. Birmaher B, Brent D. AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526.

2. Lewinsohn PM, Clarke GN, Seeley JR, et al. Major depression in community adolescents: age at onset, episode duration, and time to recurrence. J Am Acad Child Adolesc Psychiatry. 1994;33(6):809-818.

3. Emslie GJ, Kennard BD, Mayes TL. Predictors of treatment response in adolescent depression. Pediatr Ann. 2011;40(6):300-306.

4. Lewinsohn PM, Rohde P, Seeley JR, et al. Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. Am J Psychiatry. 2000;157(10):1584-1591.

5. Foley DL, Goldston DB, Costello EJ, et al. Proximal psychiatric risk factors for suicidality in youth: the Great Smoky Mountains Study. Arch Gen Psychiatry. 2006;63(9):1017-1024.

6. Gould MS, Greenberg T, Velting DM, et al. Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2003;42(4):386-405.

7. Weiss B, Garber J. Developmental differences in the phenomenology of depression. Dev Psychopathol. 2003;15(2):403-430.

8. Calles JL, Jr. Depression in children and adolescents. Prim Care. 2007;34(2):243-258abstract vi.

9. Farmer TJ. The experience of major depression: adolescents’ perspectives. Issues Ment Health Nurs. 2002;23(6):567-585.

10. Zalsman G, Brent DA, Weersing VR. Depressive disorders in childhood and adolescence: an overview: epidemiology clinical manifestation and risk factors. Child Adolesc Psychiatr Clin N Am. 2006;15(4):827-841, vii.

11. Cotton S, Larkin E, Hoopes A, et al. The impact of adolescent spirituality on depressive symptoms and health risk behaviors. J Adolesc Health. 2005;36(6):529.-

12. Birmaher B, Arbelaez C, Brent D. Course and outcome of child and adolescent major depressive disorder. Child Adolesc Psychiatr Clin N Am. 2002;11(3):619-637, x.

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14. Reich W. Diagnostic interview for children and adolescents (DICA). J Am Acad Child Adolesc Psychiatry. 2000;39(1):59-66.

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16. Ambrosini PJ. Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). J Am Acad Child Adolesc Psychiatry. 2000;39(1):49-58.

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19. Weisz JR, McCarty CA, Valeri SM. Effects of psychotherapy for depression in children and adolescents: a meta-analysis. Psychol Bull. 2006;132(1):132-149.

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Although depression affects nearly 2% of children (age ≤12) and up to 10% of adolescents (age 13 to 18),¹ the disorder often is underdiagnosed and undertreated in pediatric patients.² Treating depression in young patients is challenging. Only 30% to 40% of depressed children and adolescents who receive evidence-based treatment achieve remission.³ In addition, 50% to 70% of those who initially achieve remission will experience recurrence within 5 years.⁴ Suicide is the third leading cause of death among children and adolescents, and depression greatly increases the likelihood of suicide.^5,6

This article reviews assessing and treating depression in children and adolescents, and how to lower suicide risk in pediatric patients.

Symptoms vary with age

Depressive symptoms vary as a function of the child’s cognitive development and social functioning. Hopelessness and vegetative and motivational symptoms may be more frequent in adolescents than in children.⁷

In preschool-age children, depression manifests indirectly through somatic symptoms and behavioral disturbances. In this age group, sadness or irritability are sensitive and predominant symptoms of depression.⁸ In older children, sadness and loss of interest in social activities may indicate depression. In adolescents, feelings of mental and physical weariness, aloneness, disconnectedness, uncertainty, vulnerability, anger, irritability, and ambivalence toward friends suggest a depressive disorder.⁹

Clinical Point

In children and adolescents, subsyndromal depressive symptoms, relapse, and recurrence are common

Genetic predisposition to depression, poor family support, dysfunctional parenting, and individual vulnerabilities such as poor self-esteem or emotional dysregulation may increase young patients’ risk for depression.¹⁰ Peer and family support may protect against depression. Personal competence stemming from social acceptance and body image satisfaction also may be protective factors. A sense of religious and existential well-being (finding meaning and purpose in life) are significantly associated with lower rates of depression among adolescents.¹¹

A persistent illness

The mean duration of a depressive episode in children and adolescents is 7 to 8 months.¹² However, subsyndromal depressive symptoms—as well as relapse and recurrence—are common. Long-term studies indicate that many depressed adolescents experience depressive episodes into adulthood.¹² Factors that may predict recurrence in adulthood include:

severity of depressive episodes
concurrent psychotic symptoms
suicidal thoughts
history of recurrent depressive episodes
threshold residual symptoms
recent stressful life events
adverse family environment
family history of depression.¹²

Early symptom onset, greater depression severity, suicidality, presence of comorbid anxiety, disruptive disorders, and an adverse family environment also predict longer recovery time.¹² A study of depressed adolescents found that a history of recurrent depression, family history of recurrent depression, personality disorder traits, and (for girls only) conflict with parents predicted recurrence of depression in young adulthood.⁴Table 1 summarizes factors that affect depression outcomes in children and adolescents.

Table 1

What affects depression outcomes in children and adolescents?

Factor	Outcomes
Age	Pharmacotherapy and CBT are equally effective in younger and older adolescents.^a Although age does not affect long-term treatment outcomes, older adolescents (age 18 to 19) with treatment-resistant depression may respond better to a combination of CBT and medication^b
Sex	Females are more likely to experience relapse.^c However, sex does not influence response to initial treatment^c
Socioeconomic status	Adolescents with high socioeconomic status are more likely to respond to CBT
Illness characteristics	Severity of depression is the strongest predictor of poor outcome.^d-f Patients with moderate depression are more likely to benefit from CBT added to medication.^g However, adding CBT to medication did not affect outcomes in adolescents with self-injurious behavior.^b,f Suicidal behaviors during treatment are less frequent when CBT is combined with medication^h,i
Substance abuse	Patients with substance use disorders are less likely to respond to depression treatment^f and those who continued to abuse substances during treatment are less likely to achieve remission than those who abstain^b
Cognitive measures	Higher levels of hopelessness are associated with poor outcomes. For adolescents with treatment-resistant depression who experience hopelessness, adding CBT to pharmacotherapy did not provide additional benefit. Some studies have noted that adolescents with cognitive distortions are more likely to benefit from CBT plus pharmacotherapy^b
Family characteristics/environment	High family stress is associated with poor treatment outcomes.^f Experiencing loss and physically dangerous events does not affect depression outcomes. Trauma and history of abuse adversely effect depression treatment outcomes
CBT: cognitive-behavioral therapy Birmaher B, Brent D; AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503-1526. Emslie GJ, Mayes T, Porta G, et al. Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes. Am J Psychiatry. 2010;167(7):782-791. Curry J, Silva S, Rohde P, et al. Recovery and recurrence following treatment for adolescent major depression. Arch Gen Psychiatry. 2011;68(3):263-269. Wilkinson P, Dubicka B, Kelvin R, et al. Treated depression in adolescents: predictors of outcome at 28 weeks. Br J Psychiatry. 2009;194(4):334-341. Curry J, Rohde P, Simons A, et al. Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45(12):1427-1439. Asarnow JR, Emslie G, Clarke G, et al. Treatment of selective serotonin reuptake inhibitor-resistant depression in adolescents: predictors and moderators of treatment response. J Am Acad Child Adolesc Psychiatry. 2009;48(3):330-339. Emslie GJ, Kennard BD, Mayes TL. Predictors of treatment response in adolescent depression. Pediatr Ann. 2011;40(6):300-306. Emslie G, Kratochvil C, Vitiello B, et al. Treatment for Adolescents with Depression Study (TADS): safety results. J Am Acad Child Adolesc Psychiatry. 2006;45(12):1440-1455. Vitiello B. Combined cognitive-behavioural therapy and pharmacotherapy for adolescent depression: does it improve outcomes compared with monotherapy? CNS Drugs. 2009;23(4):271-280.