Major Depressive Disorder in Children & Adolescents PDF

**Child & Adolescent Psychiatry** **Mood Disorders in Children and Adolescents** **Major Depressive Disorder** **Dr. Elina Dirani** Most mental disorders in adults have their origins in childhood. Most mental disorders in children have persistent impact well into adulthood, if not treated early...

**Child & Adolescent Psychiatry** **Mood Disorders in Children and Adolescents** **Major Depressive Disorder** **Dr. Elina Dirani** Most mental disorders in adults have their origins in childhood. Most mental disorders in children have persistent impact well into adulthood, if not treated early. **Major Depressive Episode** (MDE) and **Major Depressive Disorder** (MDD) is possible in children even of preschool age. Depressive disorder starting between 5-12 years of age poorer prognosis compared to those with later onset. Episodes are more frequent and more severe, higher risk of comorbidities, suicidality, visits to the ED, functional impact, lower quality of life, etc. **Major Depressive Disorder** It is important to check if at least 5/9 symptoms are apparent in the last 2 weeks. **!! 2 major symptoms:** - Depressed mood (sad, not happy) - No interest and no pleasure in the activities done. Children can be mad and irritable, not calm, and cry instantly. **Other symptoms** - Weight loss - Insomnia or sleeping a lot - Psychomotor agitation or slow + retardation in movement - Fatigue - Worthlessness + feeling of guilt (very common) - No capacity to concentrate - Recurrent thoughts of death (very severe/ very risky) **Prevalence of MDD** Children: 1-2% Sex Ratio= 1F:1M Adolescents: 4-5% Sex Ratio= 2F:1M Adults: 15-20% Sex Ratio= 3F:1M No difference in prevalence between high-income countries and medium and low-income countries. **Particularities in Children** - Irritable mood - (Separation) anxiety - Externalized behaviors (more aggressive). In adults, there is more distress rather than externalized behavior - Irrational fear - Somatic complaints - Sleeping difficulties - Insufficient weight gain and loss - Psychomotor retardation - Significant change in behavior - Dark thoughts - Related death questions - Suicidal thoughts We should always be aware that these behaviors were not found in the child before. The child is not the same as before !! Adults commit suicide with medication and phlebotomy. Children commit by hanging/ suffocation and defenestration. **!! Cause:** - Environmental factors - Genetic predisposition - Psychological **Natural History** Anxiety symptoms often appear 1 or 2 years ahead of the onset of major depression, both in children and adults. Usually in 1 year, the depressive episode will go away. However, all the impact throughout the year affects his school life, social life, might even progress to suicide. Could start depressive episodes and progress to suicide or bipolar disorder if not treated. 80% of patients that have MDE with relapse. **Diagnosis & Orientation** Diagnosis could be difficult owinf to the variety of possible clinical presentations. Screening scales: - Children's Depression Inventory 2 (self-questionnaire) - Hamilton Rating Scale for Depression (clinician-questionnaire) Majority of children and adolescents with depression will be seen by general practitioners, pediatricians and other 1^st^ line professionals. It is therefore important to systematically ask about mood and interests. Referral to a specialist in case of: - **Moderate to severe MDE** - **Atypical features** - **Poor or no response to treatment** These same criteria could indicate the need for hospitalization and in-patient management for closer monitoring of the suicidal risk, rehydration and refeeding, diagnostic investigations and therapeutic adaptations **Management** Objectives: - **Full** symptomatic and functional remission - Development of **resilience** against future adversities Basic measures: - Good sleep hygiene, healthy diet, regular physical exercise - Smoking cessation, as well as any other potentially harmful substances - Social assistance (housing, employment) General interventions: - Patient and parent psychoeducation - Support groups Specific interventions: - **Psychotherapies** - **Pharmacotherapies**: antidepressants - **Electroconvulsive therapy** (ECT) and other brain stimulation techniques: transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), deep brain stimulation (DBS), transcranial direct current stimulation (tDCS) (very severe and resistant cases) **In practice** - **Mild MDE:** supportive psychotherapy - **Moderate MDE**: CBT, 1^st^ line. Adding antidepressant is 2^nd^ line if CBT is not enough after 6-8 weeks of therapy (sooner according to some authors) - **Severe MDE:** CBT and antidepressant from the start **!!** For children, the medicine needs 2-3 weeks to start showing results. **Duration of AD treatment** - 1^st^ episode: at least 6-12 months - 2^nd^ episode: at least 2-3 years - 3rd episode: lifelong treatment **ECT**: very severe, life-threatening, or treatment-resistant MDE **Disruptive Mood Dysregulation Disorder** It differs between bipolarity and chronic irritability. Risk of progression towards depression and bipolar disorder. The child surprisingly starts abusing and getting angry having an uncontrollable reaction to something silly. **Persistent Depressive Disorder** Depressive symptoms usually less severe than in MDD but lasting forever. Starts at a younger age with a heavier functional impact. It last only for at least 1 year (children) and 2 years (adults) of mild symptoms. **Premenstrual Dysphoric Disorder** PMS but pathological. It differs from PMS by the absence of a minimal number of requires symptoms as well as by the fact that mood symptoms are usually minimal to absent. **Adjustment Disorders** Severe distress and sadness caused by a big trauma. 3 months of distress as a result of a traumatic event. Maladaptive reaction to one or more stress factors, but not severe enough to be considered as MDD or an anxiety disorder. Children pass through a period of regression (bedwetting, thumb sucking, baby talk, requiring help for feeding, etc.) Spontaneous evolution is generally favorable. **Conclusion and Key Messages** MDD can occur in children and especially adolescents and usually has a poorer prognosis than MDD with later onset Clinical presentation in children differs from that in adults: irritability, somatic complaints, behavioral problems. Main assessment criterion = any recent and significant change in behavior Even though social and cultural factors do play a role, it is genomic and biological factors that ultimately drive the occurrence of the disorder, following a vulnerability-stress model It is a highly recurrent disorder. Suicide is a lethal complication CBT (behavioral activation + cognitive restructuration) is the 1st line treatment for MDE in children SSRIs are the 1st line medical treatment, in combination with CBT (only Fluoxetine and Escitalopram have official authorizations) ECT is indicated in very severe, life-threatening, or treatment-resistant MDE, or MDE with specific features