Child and Adolescent major depressive disorder and dysthymic disorder are common, familial, chronic and recurrent that usually continues through adult life if left untreated.
These disorders more often then not appear earlier in life and accompanied by co morbid psychiatric conditions, like suicide, behavioral problems and substance abuse. Frequently associated with poor psychosocial functioning, academic performance and familial interaction. Hence increased need for early identification and treatment.
Two major treatment modalities psychotherapy and medications have been found to be beneficial for treatment of acute stage of depressive disorder. Based on the current literature and clinical experience psychotherapy may be the first line of treatment, However antidepressant medications must be considered for those who have co morbid conditions like, psychosis, sever depression and those who did not respond to adequate trial of psychotherapy.
Further research is needed to establish the etiological factors and efficacy of different treatment combinations, treatment resistant depression and other categories of depression (like dysthymia, bipolar depression) etc.
Major depressive disorder
Epidemiology
The prevalence of Major depressive disorder children is approximately 2% and in Adolescent is 4% to 8% with slight female preponderance during adolescent period. ( Fleming and Offord, 1990; kashani et al., 1987a, b; Lewinsohn et al., 1994a).
Biological, psychosocial and cognitive factors have been attributed to increased depression during adolescent period particularly in female (girls enter puberty earlier then boys). ( Bemporad, 1994; Nolen-Hoeksema and Girgus, 1994; Orvaschel et al., 1997; Rutter, 1991).
Studies have suggested that each successive generation since 1940 is at greater risk for developing depressive disorders and that these disorders are being identified at a younger age (Kovasc and Gatsonis, 1994; Rayan et al., 1992)
Clinical Presentation
Diagnosis of MDD according to DSM-IV (APA, 1994) Criteria’s are a child must have 2 weeks of pervasive change in mood either depressed or irritable and/or loss of interest and pleasure. In addition the child must have other clinical characteristics, including significant change in patterns of appetite, weight changes, sleep, activity, concentration, energy level, self esteem, and motivation. Symptoms must represent a change from previous functioning and produce impairment in relationships or in performance of activities. Furthermore, symptoms must not be attributable only to substance abuse, use of medications, other psychiatric illness, bereavement, or medical illness.
The clinical picture of childhood depression is significantly different across different developmental stages and diverse ethnic groups but parallels the symptoms of adult MDD (Birmhahercetal., 1996a; Kovacs, 1996; Mictchell et al., 1988; Ryan et al., 1987).
As compared to adults children usually present with symptoms of anxiety (Including phobia, and separation anxiety), somatic complaints, and auditory hallucinations. Also children may express irritability and frustration with temper tantrums and behavioral problems instead of verbalizing feelings.
Clinical Variants
Psychotic depression.
Depression associated with mood congruent or incongruent hallucinations (usually auditory) and/or delusions.
Psychotic depression has been associated with more severe depression, greater long term morbidity, resistant to antidepressant mono therapy (Haley et al., 1988; Strober et al., 1993).
Bipolar depression
Child and adolescent population more likely to present with rapid cycling or mixed mood states which are difficult to treat and increase the risk of suicide (Brent et al., 1988, 1993b; Geller and Luby, 1997
Atypical depression
Hypersomnia, increased appetite, craving for carbohydrate (Stewart et al., 1993)
Seasonal affective disorder
Seasonal affective disorder is known in youth who lives in regions with distinct seasons. It manifests in youth like atypical depression except it does not include sensitivity to rejection and is episodic; it should be differentiated from depression triggered by school stress.
Sub clinical depression
Usually occur before or after an episode of Major depression.
Treatment resistant depression
6% to 10% depressed youth may suffer from chronic depression (Kovacs, 1996; Sanford et al., 1995; Strober et al., 1993)
Co morbidity
The most frequent co morbid diagnosis are dysthymia and anxiety disorders (both at 30% to 80%), disruptive disorder (10% to 80%) and substance use disorder (20% to 30%)
Differential diagnosis
Nonaffective disorders
Patients with nonaffective disorders (e.g., anxiety disorders, learning disabilities, or disruptive disorders) may have poor self esteem and feel demoralized and mimic MDD.
Adjustment disorder with depressed mood
Excessive change in mood and impairment of functioning within 3 months of an identifiable stressor. Over all those disorder is self limited and associated with less severe mood disturbance, fewer symptoms, and no relapse (Kovascs et al., 1994b)
General medical conditions
Cancer hypothyroidism, Lupus erythematosus, AIDS, anemia, diabetes and epilepsy may be accompanied by symptoms of depression (burke et al., 1989; Kovacs et al., 1996).
Bereavement
The acute phase of uncomplicated bereavement usually remits spontaneously within 6months to 1 year. The diagnosis of MDD should be considered if bereavement is associated with moderate to severe functional impairment, psychosis, suicidality, and/or prolonged course.
Clinical course
Episode duration
The median duration of a major depressive episode for clinically referred youth is 7 to 9 months. Approximately 90% of MDD remit 1 to 2 years after onset, with 6% to 10% becoming protracted (Emslie et al., 1997a; Harrington et al., 1991;
Relapse
After successful acute therapy, approximately 40% to 60% of youth with depression experience a relapse. ( Emslie et al., 1997a; Kovacs, 1996.
Recurrence
Longitudinal studies of both clinical and community samples of depressed youth have shown that the probability of recurrence reaches 20% to 60% by 1 to 2 years after remission and climbs to 75% after 5 years, depending upon the severity of depression and time interval that is examined(Emslie et al., 1997a; Kovacs, 1996.
Risk of bipolar disorder
20% to 40% youth with MDD develop Bipolar disorder within 5 years after the onset MDD ( Geller and Luby, 1997; Kovacs, 1996.
Factors associated with clinical course
Demographics.
The risk of depression increases by a factor of 2 to 4 after puberty, particularly in girls ( Weissman et al., 1997).
Genetic and familial factors.
Family twin and adoption studies have provided evidence that both genetic and environmental factors play a role in the pathogenesis of MDD ( Kendler, 1995; Plomin, 1994).
Psychopathological factors
A history of previous depressive episode, subsyndromal symptoms of depression, dysthymia and anxiety disorders increase the risk of future depression (Kovacs, 1996; Kovacs et al., 1994a; Lewinsohn et al., 1994a, b; Reinherz et al., 1993).
Educational functioning
Language and learning disability, ADHD, school phobia and any other condition that interfere with a child’s learning, therefore, easily can increase the risk for depression (AACAP, 1998a).
Psychodynamic factors
Personality dynamics, Such as unrealistic, often harsh, internal judgment of the child’s own impulses, thoughts and affects, particularly those that are aggressive or angry in content, may contribute to the development of depression. These dynamics contribute to low self esteem and shame, which are prominent in MDD.
(Personality dynamics)
Cognitive style and temperament
Youth who has negative attributional styles for interpreting and coping with stress and negative life events tend to become hopeless and dysphoric and appear to be a higher risk of developing MDD ( Garber and Hilsman, 1992).
Early adverse experience
There is evidence that adverse experience (e.g., Death of parents or separation) during childhood and adolescent raise the risk for depression or anxiety in adulthood ( Birmaher et al., 1996a; Garber and Hilsman, 1992).
Exposure to negative life events
The negative events may be either independent of the person’s behavior (e.g., death of a parent) or generated by the person’s maladaptive behaviors.
Family relationships
Studies of depressed adults recalling their early family relationship, children of depressed parents, and depressed youth have shown that their family interaction are characterized by more conflict, child maltreatment, rejection, and problems with communication, compared with families of normal controls (Beardslee et al., 1996a; Harrington et al., 1997).
Biological factors
An area of current interest is dysfunction in the ability to regulate emotions or distress, which may predispose youth to develop depression (Gross and Munoz, 1995).
Sequelae
Youth with MDD are at high risk for suicidal behavior; substance abuse, including nicotine dependence;Physical illness; early pregnancy; exposure to negative life events; and poor work, academic, and psychosocial functioning (Birmaher et al., 1996a; Kovacs, 1996).
Assessment
Comprehensive psychiatric diagnostic evaluation (including pt interview and collateral information) is the single most useful tool currently available to diagnose depressive disorders.
Different rating scales available beck depression inventory.
Treatment of major depressive disorder
The treatment always should be adapted to the developmental stage (e.g., cognitive functioning, social maturity, capacity to sustain attention) of the children or adolescent.
Treatment relationship and education
Affective therapeutic alliance should be fostered very early in the treatment, to maintain patient and family involvement over the course of treatment. Another critical component of the early treatment for MDD is education of the patient and his or her family about the disorder and its treatment (Beardslee et al., 1997a, b; Brent et al., 1993d).
Acute treatment phase
Opinion varies about whether psychotherapy or pharmacotherapy, or a combination, should be offered as first-line treatment for children and adolescent with MDD. Further more which psychotherapy among available (e.g., psycho dynamic psychotherapy, CBT, IPT) or which component of the psychotherapies is most efficacious (Jacobson et al., 1996).
Psychotherapy
Psycho therapeutic techniques are used to teach patients and families to cope with past and current stresses, improve coping skills and self esteem, and understand themselves and cope with interpersonal conflict and the social, familial, academic and occupational problems that are associated with depression. Psycho dynamic psychotherapy, IPT, CBT, behavior therapy, family therapy, supportive psychotherapy, and group therapy have been used for the treatment of youth with MDD (Bemporad, 1994; birmaher et al., 1996b).
Pharmacological interventions
There are very few studies on the use of medications for youth with MDD, and these studies are open or have methodological problems (Mandoki et al., 1997; Ryan et al., 1988b).
Clinician should inform the dose, timing, affects, duration and side effects of medications
Continuation treatment phase
Given the high rate of relapse and recurrence of depression, continuation therapy is recommended for all patients for at least 6 to 12 months.
Maintenance treatment phase
Once the pt has been asymptomatic for 6 to 12 months, the clinician must decide whether maintenance therapy is indicated to whom to administer maintenance therapy, which therapy, and for how long. The main goal is to foster healthy growth and development and prevent relapse and recurrence.
Treatment of variants of MDD
Treatment resistant depression
Combination Antidepressant and/or SNRI and/or augmentation with Atypical anti psychotic
Sub clinical depression
Dependant upon symptoms severity, Usually respond to Combination Antidepressant and Psychotherapy
Atypical depression
Usually respond to Combination Antidepressant and Psychotherapy
Bipolar depression
Mood stabilizer and/or Atypical anti psychotic/Psychotheay
Psychotic depression.
Atypical anti psychotic and/or antidepressants/Psychoherapy