Chapter 38. Depressive Disorders (in Childhood and Adolescence)

DSM-IV-TR Diagnostic Criteria

Major Depressive Episode

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

   Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions and hallucinations.

   1. depressed mood. Note: In children and adolescents, can be irritable mood

   2. loss of interest or pleasure (anhedonia)

   3. significant weight loss when not dieting or weight gain, or decrease or increase in appetite. Note: In children and adolescents, can be failure to make expected weight gains

   4. insomnia or hypersomnia

   5. psychomotor agitation or retardation

   6. fatigue or loss of energy

   7. feelings of worthlessness or inappropriate/excessive guilt

   8. diminished ability to think or concentrate, or indecisiveness

   9. recurrent thoughts of death or suicide

2. The symptoms do not meet criteria for a mixed episode.

3. The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.

4. The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse) or a general medical condition (e.g., hypothyroidism).

5. The symptoms are not better accounted for by bereavement (i.e., depressive/grief symptoms lasting less than 2 months).

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 American Psychiatric Association.)

In this chapter, we describe the characteristics and epidemiology of unipolar depressive disorders in children and adolescents, etiologic risk factors for depression onset and recurrence, and assessment and differential diagnosis of depressive disorders. We review recommended psychosocial and pharmacological treatments, and in conclusion, suggest areas for future investigation.

Child and adolescent depressive disorders are common, often recurrent, and generally continue into adulthood. These disorders are often familial, and are associated with additional morbidity and mortality from comorbid substance abuse and from suicide and suicidal behavior. Patients also suffer educational and later occupational underachievement as well as relationship difficulties. Therefore, early identification and treatment of these conditions are important public health issues.

Epidemiology

The estimated prevalence of MDD is 2% in children and 4–8% in adolescents. After puberty, the risk for depression increases two- to fourfold, with 20% incidence by the age of 18 years. The gender ratio in childhood is 1:1, with an increase in the risk for depression in females after puberty, when the male/female is estimated at 1:2. This may be related to higher rates of anxiety in females, changes in estradiol and testosterone at puberty, or sociocultural issues related to female adolescent development.

It is important to differentiate childhood-onset from adolescent-onset depression. Depressive disorders in adolescence are much more likely to be recurrent into adulthood. In the context of significant family adversity, prepubertal depression is most often comorbid with behavioral problems. A less common form of childhood prepubertal ...