Depression in Adolescents

Key Points

• Routine screening, with a validated tool if available, for depression in adolescents is recommended annually
  • US Preventive Services Task Force recommends screening for MDD (major depressive disorder) in adolescents aged 12 to 18 years⁶
  • American Academy of Pediatrics recommends that adolescent patients aged 12 years and older be screened annually for MDD with a formal screening tool such as the PHQ (Patient Health Questionnaire) or the Patient Health Questionnaire for Adolescents^3,6,7,8
• Clinical interview should be utilized to assess for depressive symptoms
• Based on the severity of symptoms, clinicians can treat patients with antidepressants, or refer to mental health specialists for ongoing treatment (with/without medications and/or therapy)
• Evaluate for suicide risk by performing a standardized suicide risk screen in adolescent patients struggling with depression and follow a positive screen with a Brief Suicide Safety Assessment^18,20
• Work with patients, families, and mental health partners to develop safety plans for patients struggling with suicidal thoughts^18,20

Alarm Signs and Symptoms

• Common warning signs may include, but are not limited to:¹⁸
  • Talking about killing oneself, feeling hopeless, feeling like a burden, or having no reason to live
  • Mood changes, including depression, anxiety, and agitation
  • Behavior changes:
    • Increased substance use
    • Withdrawing from activities
    • Isolating from family and friends
    • Sleeping too much or not enough
    • Giving away prized possessions
    • Irritability

Background Information

• MDD (major depressive disorder) in adolescents is a serious psychiatric illness with extensive morbidity and mortality that remains underdiagnosed before adulthood¹

Epidemiology

• Between 2013 and 2019, one-fifth (20.9%) of children and adolescents aged 12 to 17 years surveyed reported a prior major depressive episode²
• MDD in children and adolescents is associated with recurrent depression in adulthood, other mental health disorders, an increased risk for suicidal ideation, suicide attempts, and death by suicide³
• Suicide is the second-leading cause of death among children and adolescents aged 10 to 19 years³

Etiology and Risk Factors

Approach to Diagnosis

• Clinicians should combine depression-specific screening tools and patient interviews to arrive at an accurate diagnosis³
• Screening
  • Screening is the first step in making a diagnosis of depression³
  • Early identification of depression in adolescent patients can guide early intervention, treatment, and self-management skills⁵
  • Most commonly used screening test in clinical practice is the PHQ (Patient Health Questionnaire)^6,7
  • Patient Health Questionnaire for Adolescents is a validated screening tool specifically designed for adolescent patients⁸
• Assessment
  • A high score on a screening tool alone does not make for a diagnosis of MDD³
  • Initial presentation of depressive disorders may be variable
    • Symptoms may include sad or irritable mood, feelings of emptiness or boredom, somatic complaints, fatigue, social withdrawal, declining school performance, familial conflict, or a decline in self-care^3,5
  • A commonly used mnemonic for symptoms of MDD is "SIGECAPS"⁹
    • Sleep disorder (either increased or decreased sleep)
    • Interest deficit (anhedonia)
    • Guilt (worthlessness, hopelessness, regret)
    • Energy deficit
    • Concentration deficit
    • Appetite disorder (either decreased or increased)
    • Psychomotor retardation or agitation
    • Suicidality

Diagnostic Criteria

• MDD is characterized by a discrete episode lasting at least 2 weeks in duration involving clear changes in mood, interest/pleasure, cognition, and neurovegetative functions^5,10,11
  • Symptoms must be present for most of the day, nearly every day, and must result in clinically significant distress or functional impairment^5,10,11
  • Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from prior functioning^5,10,11 These symptoms correspond to the PHQ⁷
    • At least 1 of the symptoms is either:
      • Depressed mood or irritable mood
      • Loss of interest of pleasure or anhedonia
      • Changes in appetite or weight
      • Insomnia or hypersomnia
      • Psychomotor agitation or retardation (observed)
      • Fatigue or loss of energy
      • Feelings of worthlessness, excessive feelings of guilt
      • Impaired decisiveness or concentration
      • Recurrent thought about death, dying, suicidal ideation or attempt
  • Alternative medical, substance, or psychiatric explanations, hypomanic/manic episodes must be ruled out^5,10,11

History

• Clinicians should interview the adolescent privately; however, it is important to remind patients that safety concerns (related to suicidal ideation) take precedence over confidentiality¹²
  • Adolescents should be informed of this before the interview¹²
• Evaluate for risk factors: personal or family history of mental health diagnoses, suicide-related behaviors, substance use, significant psychosocial stressors, and/or trauma history³

Physical Examination

• Elements of the mental status exam, including general appearance (ie, self-care, hygiene), speech, mood and affect, thought process, thought content, perceptual disturbances (ie, hallucinations), sensorium and cognition, insight, and judgment, can help to rule in/out specific psychiatric or neurologic disorders^13,14

Approach to Treatment

• Appropriate treatment depends on symptoms and symptom severity (Figure 1)
• For patients with mild depressive symptoms:
  • Provide active support to patients and families for 6 to 8 weeks, checking in every 1 to 2 weeks¹⁵
  • If symptoms resolve, continue routine follow-up and screening¹⁵
  • If symptoms worsen, consider more active intervention (medication, psychotherapy, and/or referral)¹⁵
• For patients with moderate depressive symptoms:
  • Consider referral to mental health specialist or manage within primary care¹⁵
  • If managing within primary care: initiate medication and/or therapy¹⁵
  • If partially improved after 6 to 8 weeks: consider adding medication (if not already done), increasing to max dose, adding therapy if not done already, consulting with mental health specialist¹⁵
  • If not improved after 6 to 8 weeks: reassess diagnosis¹⁵
    • Same steps as above (see "If partially improved")
• For patients with severe depressive symptoms or significant comorbidities:
  • Consider consultation by a mental health specialist¹⁵

Nondrug and Supportive Care

• Familial involvement is necessary for all phases of depression management³
• Cultural factors should be considered when working with patients with depression^3,16
• Options for MDD (major depressive disorder) treatment in adolescents include psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine techniques³
• Sleep hygiene, proper nutrition, and physical exercise can be important elements of overall wellness in adolescents¹⁵
• Maintain contact with mental health specialist if patient continues with therapy¹⁵

Drug Therapy

• Antidepressants with or without other forms of therapy are an effective treatment for depression in adolescents¹⁵
• Fluoxetine is FDA approved for use in children and adolescents aged 8 years and older with MDD¹⁵
• Escitalopram is FDA approved for use in adolescents aged 12 years and older with MDD¹⁵
• Sertraline is FDA approved for use in children and adolescents with obsessive-compulsive disorder, but has been shown to be safe and effective in the treatment of MDD in children and adolescents¹⁷
• Adolescents should have some clinical response at 2 to 3 weeks of therapeutic dose¹⁵
  • If a response is not noted at this time, increase the dose¹⁵
  • If a response is seen, continue for 4 to 6 weeks and reassess dose¹⁵

• Table 2. SSRI titration schedule for the treatment of MDD in adolescents.¹⁵

  SSRI, selective serotonin reuptake inhibitor.

  *These medications are contraindicated with concurrent use with monoamine oxidase inhibitors.

  Data from Cheung AH et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC). Treatment and ongoing management. Pediatrics 2018;141(3):e20174082.

  Medication*	Starting dose (every day)	Increments	Effective dose	Maximum dosage
  Fluoxetine	5 to 10 mg	10 to 20 mg	20 mg	60 mg
  Sertraline	25 mg	12.5 to 25 mg	50 mg	200 mg
  Escitalopram	5 to 10 mg	5 mg	10 mg	20 mg

Monitoring

• All antidepressants have an FDA black-box warning for children and adolescents stating that pediatric patients being treated with antidepressants for any indication should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases¹⁵
• After initiating treatment with medications, patients should be evaluated within 1 week to assess for presence of or increasing suicidal thoughts¹⁵
• While titrating the medication dosage, patients should be monitored every 1 to 2 weeks¹⁵
  • Assess for depressive symptoms, suicidality, and potential adverse effects from treatment¹⁵
  • Common mild side effects include dry mouth, constipation/diarrhea, irritability, disinhibition, headache, appetite change¹⁵
  • More serious side effects may include akathisia, serotonin syndrome, hypomania¹⁵
  • If side effects are mild, wait 2 to 7 days to see if symptoms are transient or tolerable¹⁵
  • If side effects are moderate, reduce or change the dosing schedule¹⁵
  • If side effects are severe, discontinue therapy¹⁵
• If symptoms are improved after 6 to 8 weeks of treatment, monitor with regular follow-up monthly for 6 months postsymptom resolution, and continue medication for a year after full resolution of symptoms¹⁵

Complications

• Suicide risk can occur at any phase of screening, assessment, and treatment for depression¹⁵
• Engage in open discussion with patients and families around suicide, implement suicide risk screening, and include safety planning in management plans^12,15,18

Prognosis

• Recovery rates for MDD (major depressive disorder) in adolescents are high, though recurrence is possible in the years following initial treatment¹⁹