Depression in Children and Adolescents ?
Q.Major depression in the pediatric population is readily diagnosable using DSM-IV criteria, i.e. the criteria sets work. Nevertheless, there are clear age-related differences between children, adolescents and adults in depressive symptoms and associated features. For example, adolescents are more likely to complain of feeling sad without looking sad, whereas younger children and adults also look sad when depressed.
A.major depression is commonly comorbid with other internalizing and externalizing disorders. The anxiety disorders often precede MDD, especially in younger children. Subtle anxiety symptoms sometimes remain when depressive symptoms resolve, and may form the nidus for a recurrent depressive episode. Conduct disorder and substance abuse may pose a significant problem in depressed adolescents. Comorbid disruptive behaviors may signal comorbid bipolarity in a substantial number of depressed acting out youth. Conversely, while ADHD and hypomania overlap symptomaticallyand most if not all children with bipolar disturbances meet DSM criteria for ADHDfew children with ADHD are bipolar. Absent thought disorder symptoms and/or clear mania, our practice is to treat ADHD symptoms first and only then to target residual affective symptoms are representing bipolarity. While the population prevalence of suicide in the context of depression is unknown, affective illness (especially bipolar disorder) is a principal risk factor for suicide attempts, and even more, for completed suicide. Other risk factors include coincident post-traumatic symptomatology, including borderline personality disorder; conduct disorder and substance abuse or dependence; and ongoing psychosocial adversity. When these factors are present, and the youngster shows signs or symptoms of aggression toward self or others, safety becomes the primary consideration. the empirical literature on psychopharmacological interventions in MDD was at best unconvincing with respect to efficacy. In particular, nine controlled studies have now shown no benefit for TCAs in depressed children or adolescents. Given the small but real risk for cardiovascular morbidity with TCAs and the poor track record of these compounds in controlled studies, this renders TCAs no longer defensible (in my view) as first line agents for depression in the pediatric population. children and adolescents with MDD should receive a comprehensive multi-perspective assessment to define treatment targets for psychotherapy, pharmacotherapy and, where appropriate, academic interventions. Currently, cognitive-behavioral or interpersonal psychotherapy are the psychotherapeutic treatments of choice. CBT and IPT can be administered individually or in groups and dovetail nicely, where necessary, with behavioral family therapy. If not rapidly responsive to psychotherapy, a selective serotonin uptake inhibitor should be added. Pharmacotherapy with a mood stabilizer is one key to the successful treatment of the bipolar youngster. In straightforward major depression, some physicians and patients will choose medication first, trying to avoid the time, effort, and anxiety associated with psychotherapy, especially with younger children.
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