Enuresis and depression

Enuresis

• Desmopressin can be used in conjunction with the enuresis alarm to speed up the acquisition of bladder control.
• Imipramine and anticholinergic agents have also been used for the treatment of enuresis.

Functional Enuresis

• Repeated involuntary voiding of urine after the age of usual continence, with no identified physical disorder.
• Can be nocturnal (bedwetting), diurnal (daytime wetting), or both.
• Most children achieve daytime and night-time continence by 3 or 4 years of age.
• Nocturnal enuresis can be primary (no preceding period of urinary continence) or secondary (preceding period of urinary continence).

Depression in Children and Adolescents

• TADS study: combination of fluoxetine and cognitive behavior therapy is the best treatment for moderate to severe depression in adolescence.
• Network meta-analysis: interpersonal therapy and cognitive behavior therapy are the most effective psychotherapies for depression in children and adolescents.

Prognosis of Depression in Children and Adolescents

• Tends to be chronic and recurrent, with 60-90% remitting within one year.
• 50-70% will develop subsequent depressive disorders within five years.
• Increased risk of depression in adulthood, associated with educational underachievement and interpersonal difficulties.

Vulnerability Factors for Depression

• Genetic factors
• Cognitive distortion and rumination
• Emotion regulation difficulties
• Behavioral disorders and irritability
• Sleep deprivation
• Comorbid medical illness

Environmental Risk Factors

• Parental depression and family discord
• Child maltreatment
• Peer victimization
• Sexual minority status
• Bereavement
• Resilience

Treatment of Depression in Children and Adolescents

• Fluoxetine has a favorable risk-benefit ratio and is the only antidepressant currently considered beneficial.
• Combination of fluoxetine and cognitive behavior therapy is more effective than fluoxetine alone.
• Clinicians should monitor for the emergence or exacerbation of suicidality, especially with SSRIs and venlafaxine.

Childhood Depression

• Clinical picture of major depression in childhood and adolescence is similar to adults, but can be easily missed.
• Symptoms may include abdominal pains, headaches, anorexia, and enuresis.

Epidemiology of Childhood Depression

• Depressive symptoms are more common in adolescence.
• Estimates of major depressive disorder are less than 1% in pre-pubertal children, with an equal ratio of males to females.
• 1-year prevalence of around 4% following puberty puts females at a greater risk, with a 2:1 ratio of females to males.

Aetiology of Childhood Depression

• Individual, family, and social risk factors are strongly correlated.
• Causes of depressive disorder are similar to that seen in adulthood.
• Major pubertal and brain and cognitive maturation processes influence the aetiology and impact of depression.

Risk Factors for Childhood Depression

• Negative cognitive biases
• Increased cortisol secretion
• Genetic factors
• 5-HTTLPR variation
• Neurobiology
• Negative life events
• Temperament

Management of Childhood Depression

• General measures: reduce distressing circumstances and stressors, encourage expression of feelings, and consider depression in parents.
• Psychological treatment: cognitive therapy, interpersonal therapy, and brief family therapy.
• Medication: SSRIs have been shown to have clinical benefit for moderate to severe depression.

Nocturnal Enuresis

• Nocturnal enuresis can cause significant unhappiness and distress, especially if parents blame or punish the child.
• Limitations on activities, such as staying with friends or going on holiday, can worsen this unhappiness.

Epidemiology

• The prevalence of nocturnal enuresis occurring once a week or more is around 10% at 5 years of age, 4% at 8 years, and 1% at 14 years in the UK.
• Similar figures have been reported from the USA.
• Nocturnal enuresis occurs more frequently in boys.
• Daytime enuresis has a lower prevalence and is more common in girls than in boys.
• Over 50% of daytime wetters also experience nocturnal enuresis.

Aetiology

• Nocturnal enuresis can be caused by physical conditions, but more often it is due to a delay in the maturation of the nervous system, often combined with environmental stressors.
• There is a genetic contribution, with around 70% of children with enuresis having a first-degree relative who has been enuretic.
• Concordance rates for enuresis are twice as high in monozygotic twins as in dizygotic twins.
• Family influences, such as exposure to family adversity and stress, parenting style, and difficulties in toilet training, can contribute to enuresis.
• Most enuretic children are free from psychiatric disorder, but the proportion with psychiatric disorder is greater than that of other children.
• Early childhood difficult temperament and behaviour problems can be risk factors for later bedwetting.
• Enuresis is more frequent in large families living in overcrowded conditions.
• Stressful events can trigger the onset of secondary enuresis.

Assessment

• A careful history and physical examination are necessary to determine if the enuresis is primary or secondary and to exclude undetected physical disorders.
• The child should be screened for other psychiatric disorders and a history taken to determine if any difficult or distressing events contributed to the presentation.
• Questions should be asked about faecal soiling and urinary infection.

Management

• Primary care and paediatric services typically treat enuresis disorders.
• Any physical disorder should be treated.
• The child and parents should be informed that the condition is common and the child is not to blame.
• Punishment and disapproval are inappropriate and unlikely to be effective.
• Rewarding success without drawing attention to failure can be helpful.
• Restricting fluid before bedtime, voiding at daytime intervals and/or before bedtime, and using star charts can be effective.
• Enuresis alarms can be used for children who do not improve with these simple measures, with high reported success rates.

Learn about the different treatment options for enuresis, including desmopressin and imipramine, as well as the role of enuresis alarms in achieving bladder control. Understand the differences between nocturnal and diurnal enuresis.