Major Depressive Disorder in Children
Whenever major depressive disorder (MDD) develops in infancy, the outcomes can be severe. Juvenile MDD is associated with poor achievement, interpersonal difficulties, early parenthood, and an increased risk of further mental health conditions and substance use disorders. Approximately 12.8 percent of the US population aged 12 to 17 experienced at least one serious depressive episode in 2016. (Mullen, 2018).
As many as 8 percent of juveniles with MDD commit suicide before attaining young adulthood, rendering suicide the second leading cause of death among 12- to 17-year-olds (Mullen, 2018). Early detection is crucial in the treatment of depressed youngsters. Pediatric MDD is treated with psychotherapy and antidepressant medications, particularly selective serotonin reuptake inhibitors.
Suicidality rises when antidepressants are begun, but it also increases when depression is left unaddressed. Furthermore, adolescent depression, to name a few risks, is a risk factor for suicide, drug use problems, and long-term psychological impairment in adulthood. This paper aims to discuss and assess and treat children with Depressive Disorders and develop a medication guide.
Pediatric MDD is frequently misdiagnosed and mistreated, with only half of all children identified before reaching adulthood. It is a prevalent, chronic, recurring, and incapacitating condition. According to Patra and Kumar (2022), a third of children who visit their general practitioner may present an emotional disorder, and only 14% may test positive for depression.
The CDC estimates that 0.5 percent of children aged 3 to 5, 2 percent of youngsters aged 6 to 11, and up to 12 percent of those aged 12 to 17 are affected (Patra & Kumar, 2022). Throughout childhood, males and girls are diagnosed comparably, although, during adolescence, females are much more typically diagnosed with depression.
Pediatric depression has been observed in toddlers as young as three years old, yet, toddlers are typically less likely to communicate their symptomatology openly or meet the DSM-5 MDD criteria. Depressed youngsters aged 3 to 8 usually have more severe somatic symptoms, are more temperamental, exhibit fewer indicators of depression, and demonstrate anxiety symptoms (American Psychiatric Association, 2013).
As children grow into teenagers and ultimately adults, their symptom presentation becomes increasingly compatible with the DSM-5 criteria. Furthermore, as compared to adults, children have less hypersomnia, more changes in weight and appetite issues, and fewer delusions.
According to American Psychiatric Association (2013), teens may have fewer symptoms of diminished energy or psychomotor slowness than adults. ADHD, anxiety, drug use disorders, and separation anxiety disorders are the most prevalent comorbidities.
Patra and Kumar (2022) state that major depressive episode generally improves and resolves within 7 to 9 months after symptomatic onset if left unchecked; conversely, children and adolescents who have stabilized following treatment frequently suffer resurgence within two years, with a 70% prevalence by year 5.
Whereas no single predictor of MDD resurgence in the juvenile demographic has been proven, younger age of diagnosis, prevalence of depressive episodes, severity of episodes, psychosocial pressures, and associated dysthymia, may all play a role. Children recover from their first crises faster than adults, have a higher chance of recurrence, and have a higher predisposition for an early shift to bipolar disease.
How Major Depression is Diagnosed
Depression has been proven to frequently coincide with other mental problems, such as substance misuse or anxiety. Therefore, early diagnosis and treatment are critical to a child’s recovery. Following a thorough psychiatric assessment, a child psychiatrist or other mental health expert will generally diagnose major depression.
An assessment of the child’s parents, in conjunction with data provided by teachers and care providers, may be helpful in obtaining a diagnosis when possible. In 2016, the United States Preventive Services Task Force (USPSTF) changed its 2009 guidelines and recommended that all teens aged Twelve to Eighteen years be screened for depression in primary care facilities on a regular basis (Patra & Kumar, 2022).
It also recommended putting suitable systems in place to ensure accurate diagnosis, appropriate treatment, and prompt follow-up. Clinical studies evaluating the efficacy of pharmaceuticals, psychotherapy, and collaborative techniques have led to the evidence-based suggestion by USPSTF. The task team, however, did not recommend routine screening for all children aged 11 and under due to a lack of evidence.
Similarly, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) advocate yearly depression screening in children aged 12 and up. The suggestions are established on the substantial incidence of depression in this age range, the importance of early detection and care of depression, and the opportunity for influencing critical growth and development at this age.
PHQ-9 is the most widely used test, with the maximum sensitivity (approximately 90%) and specificity (roughly 94%). The Patient Health Questionnaire for Teenagers (PHQ-9A) is a nine-question questionnaire designed specifically for adolescents.
It inquires about the teen’s emotions of hopelessness, loss of enjoyment, sleep issues, weakness, food problems, feelings of guilt, lack of focus, movement or speech problems, and suicidal ideas. It assigns a severity rating to each symptom depending on its frequency of occurrence.
The PHQ-9A score can vary between 0 and 27 (Tulisiak et al., 2019). A score of at least 5 is required for the diagnosis of depression. The symptoms should last at least two weeks and occur regularly. The screening tool’s nine questions are graded based on their repetition frequency.
Every symptomatology is awarded a value of 1, 2, or 3 depending on whether it happens frequently, more than half the time, or almost every day. The PHQ-9A score ranges from zero to twenty-seven. A total PHQ 9A score of zero-four suggests minor or slight depression, while a rating of five to nine indicates moderate depression (Tulisiak et al., 2019). Ratings of 10-14 and 15-19 suggest mild depression and moderately severe depression, respectively. A score of 20-27 suggests that one is suffering from severe depression (Tulisiak et al., 2019).
Medication and Treatment Options
However, mild to moderate depression is treatable with psychoeducation and psychotherapy; clinical depression may require medication. When education is provided, medication compliance improves. Psychoeducation covers signs and indicators of depression, the clinical course of the disease, the risk of recurrence, treatment options, and advice for parents living with depressed adolescents.
Individual, group and interpersonal psychotherapy (IPT) are all therapeutic options. A study by Mullen (2018) shows psychotherapy is successful for 62% of people with mild instances of MDD. A meta-analysis found that psychotherapy for MDD had a substantial but small effect size in children aged 8 to 19 (Mullen, 2018).
A randomized clinical study comparing IPT for depressed adolescents (IPT-A) to standard care in adolescents 12-18 years old with depression found that IPT-A significantly decreased depressive characteristics on the Hamilton Depression Rating Scale over 12 weeks compared to standard care (Mullen, 2018).
For moderate to severe depression and depression that poorly responds to psychotherapy, antidepressants are considered first-line therapy. Pharmaceuticals cannot be used alone to treat depressed juvenile patients but rather in conjunction with psychotherapy.
Both therapy approaches frequently begin during a symptomatic hospitalization, notably if the hospitalization is for suicidal thoughts or suicide attempts. For children with depression, selective serotonin reuptake inhibitors are the first-line antidepressant medications.
The Food and Drug Administration (FDA) has authorized fluoxetine for children aged 8 and above, while escitalopram is allowed for children aged 12 and up (FDA, 2022). Fluoxetine has the most evidence supporting its treatment in pediatric depression, with four positive randomized controlled studies.
Medication Considerations
When selecting antidepressants for pediatric patients, the nurse ought to evaluate the intensity of the depression, the timeliness of the therapeutic impact, the risk of overdose, the acute toxicity profile, medication interactions owing to cytochrome inhibition, client and caregiver preference, and comorbidities (Stern et al., 2015).
Due to its extended half-life, fluoxetine, for example, may be more appropriate for a client with a background of recurrent missed doses. Certain antidepressants may cause medication interactions owing to cytochrome P450 1A2 (fluvoxamine), 2D6 (fluoxetine, paroxetine, duloxetine, and bupropion) inhibition (Stern et al., 2015). In patients using substrates for these enzymes, these medications should be administered with discretion and titrated slowly.
Writing a Prescription
Includes the name of the patient plus additional identification information. Generally, the date of birth, pharmaceutical drug and dosage, amount to be taken, mode of administration, and frequency, amount to be supplied at the pharmacy, as well as the number of refills, and the signatures and medical identifiers of the nurse (Tulisiak et al., 2019). In Pennsylvania, treatment follow-up includes Retreat Behavioral Health which offers community and school mental health services.
Conclusion
Depression affects children, but because symptom presentation differs from that of adults, it is often misdiagnosed and undertreated. Mild depression is treated with psychotherapy, while moderate-to-severe MDD may be treated with a combination of psychotherapy and medication.
There is an increased risk of harmful consequences in children and adolescents, including an increased risk of suicidal ideation. Preventive measures might be focused on. Because they influence the course and prognosis of MDD, comorbid diseases and disorders in juvenile depression require more investigation.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596
FDA. (2022). Drugs. U.S. Food and Drug Administration; FDA. https://www.fda.gov/drugs
Mullen, S. (2018). Major depressive disorder in children and adolescents. The Mental Health Clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275
Patra, K. P., & Kumar, R. (2022). Screening for depression and suicide in children. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK576416/
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (1st ed.). Elsevier – Health Sciences Division. https://www.elsevier.com/books/massachusetts-general-hospital-psychopharmacology-and-neurotherapeutics/978-0-323-35764-7
Tulisiak, A. K., Klein, J. A., Harris, E., Luft, M. J., Schroeder, H. K., Mossman, S. A., Varney, S. T., Keeshin, B. R., Cotton, S., & Strawn, J. R. (2019). Antidepressant prescribing by pediatricians: A mixed-methods analysis. Current Problems in Pediatric and Adolescent Health Care, 47(1), 15–24. https://doi.org/10.1016/j.cppeds.2016.11.009
Major Depressive Disorder in Children Instructions
Please be mindful of plagiarism and APA format, I have included the rubric. Please use my course resources as one of my references as instructed. Please include Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.
Learning Resources
Required Readings (click to expand/reduce)
Baek, J. H., Nierenberg, A. A., & Fava, M. (2016). Pharmacological approaches to treatment-resistant depression. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 44–47). Elsevier.
Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 27–43). Elsevier.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Howland, R. H. (2008a). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 1: Study design. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 21–24. https://doi.org/10.3928/02793695-20080901-06
Howland, R. H. (2008b). Sequenced Treatment Alternatives to Relieve Depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21–24. https://doi.org/10.3928/02793695-20081001-05
Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. In J. M. Rey & A. Martin (Eds.), IACAPAP e-textbook of child and adolescent mental health. https://iacapap.org/_Resources/Persistent/a97650fb538f47bb697c47873b0e58d493684a07/A.7-Psychopharmacology-2019.1.pdf
Magellan Health. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf
Poznanski, E. O., & Mokros, H. B. (1996). Child depression rating scale—Revised. Western Psychological Services.
Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. https://doi.org/10.1002/da.22171
Yasuda, S. U., Zhang, L. & Huang, S.-M. (2008). The role of ethnicity in variability in response to drugs: Focus on clinical pharmacology studies. Clinical Pharmacology & Therapeutics, 84(3), 417–423. https://web.archive.org/web/20170809004704/https://www.fda.gov/downloads/Drugs/ScienceResearch/…/UCM085502.pdf
Medication Resources (click to expand/reduce)
U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
Review the following medications:
amitriptyline
bupropion
citalopram
clomipramine
desipramine
desvenlafaxine
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
imipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
Required Media (click to expand/reduce)
Doc Snipes. (2022, April 13). Major depressive disorders in the DSM 5 TR [Video]. YouTube. https://www.youtube.com/watch?v=q5Npw03I0t8
Note: The approximate length of this media piece is 59 minutes.
Psych Hub. (2020, October 5). Social determinants of health [Video]. YouTube. https://www.youtube.com/watch?v=17jeXGbKlTQ
Note: The approximate length of this media piece is 4 minutes.
Optional Resources (click to expand/reduce)
El Marroun, H., White, T., Verhulst, F., & Tiemeier, H. (2014). Maternal use of antidepressant or anxiolytic medication during pregnancy and childhood neurodevelopmental outcomes: A systematic review. European Child & Adolescent Psychiatry, 23(10), 973–992. https://doi.org/10.1007/s00787-014-0558-3
Gordon, M. S., & Melvin, G. A. (2014). Do antidepressants make children and adolescents suicidal? Journal of Pediatrics and Child Health, 50(11), 847–854. https://doi.org/10.1111/jpc.12655
Seedat, S. (2014). Controversies in the use of antidepressants in children and adolescents: A decade since the storm and where do we stand now? Journal of Child & Adolescent Mental Health, 26(2), iii-v. https://doi.org/10.2989/17280583.2014.938497
Assignment: Assessing and Treating Vulnerable Populations for Depressive Disorders
To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of pediatric patients requiring antidepressant therapy.
The Assignment: 5 pages
For this assignment, you will develop a patient medication guide for treatment of depressive disorders in a vulnerable population (your choice for one vulnerable patient population to choose from: children, adolescents, older adults, dementia patients, pregnant women or one not listed of your choice!). Be sure to use language appropriate for your audience (patient, caregiver, parent, etc.).
You will include non-copyright images and/or information tables to make your patient medication guide interesting and appealing. Limit your patient medication guide to 5 pages. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include a minimum of 3 scholarly supporting resources outside of your course provided resources.
In your patient guide, include discussion on the following:
Depressive disorder causes and symptoms
How depression is diagnosed for the vulnerable population of your choice, why is this population considered vulnerable
Medication treatment options including risk vs benefits; side effects; FDA approvals for the vulnerable population of your choice
Medication considerations of medication examples prescribed (see last bullet item)
What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring
Special Considerations (you must be specific, not general and address at least one for EACH category; you must demonstrate critical thinking beyond basics of HIPPA and informed consent!): legal considerations, ethical considerations, cultural considerations, social determinants of health
Where to follow up in your local community for further information
Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Please include a title page, an introduction with a purpose statement, and a summary.