1. Depression: How to diagnose and how to start treatment
Tamara Helfer, MD
Child and Adolescent Psychiatrist
St. Luke's Center for NeuroBehavioral Medicine

2. Learning Objectives:
How to recognize depression, even in children and adolescent
Understand treatment options
Improve patient care
Learn how to get reimbursed for screening tools

3. Depression per DSM-5 5 or more for 2 week period:
Depressed mood most of the day (in children/adolescents can be irritable mood)
Marked diminished interest/pleasure in almost all activities
Decrease or increase in appetite nearly every day (in children failure to make expected weight gain)
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to think/concentrate
Recurrent thoughts of death or SI

4. Depression Facts in Children/Adolescents
About 5 % of children/adolescents in general population suffer from depression
Increased risk:
Stress
Experienced loss
ADHD
Learning disorder
Conduct disorder
Anxiety
Depression runs in families

5. Depression in children/adolescents may differ from the behavior of depressed adults
Adult Similarities
Child Specific
Depressed Mood
Persistent boredom, Low energy
Decreased Interests/Activities
Social isolation/Poor communication
Hopelessness
Extreme sensitivity to rejection/failure
Low Self Esteem/Guilt
Increased irritability, anger
Major change in sleeping/eating behaviors
Frequent complaints of physical illnesses (HAs and stomach aches)
SI or self destructive behavior
Frequent absences from school or poor performance in school
Poor concentration
Talk of or efforts to run away from home

6. Depression…
A child who used to play often with friends and now spends most of the time alone and without interests
Things that were once fun now bring little joy
May start causing trouble at home/school
Seems more irritable
A lot of times drug/alcohol use starts as a way to start trying to feel better
Because the child/adolescent may not seem sad, parents/teachers may not realize that the troublesome behavior is a sign of depression
When asked directly, these children can sometimes state they are unhappy or sad
WE NEED TO ASK!!!

7. TADS Study Treatment for Adolescents with Depression Study (TADS)
Funded by the National Institute of Mental Health (NIMH), and published in 2004
Examined three different treatments for adolescents with moderate to severe depression:
1. Prozac (Fluoxetine) vs Placebo
2. CBT (Cognitive Behavioral Therapy) vs Placebo
3. Prozac + CBT vs Placebo
12 week long study
All showed some improvement, but overall the combined treatment resulted in the better functioning and quality of life
It is the preferred treatment for speedier responses across a broad range of outcomes such as remission and recovery of function.

8. Treatment Early diagnosis and treatment are essential!!!
Early intervention has shown to improve outcomes
As the TADS showed, combined treatment (therapy + medication) is the most effective for speedier responses, for remission, and for recovery of function
About 60 percent of children and adolescents will respond to initial treatment with medication (SSRI)

9. What if no treatment…
Untreated depression can last 6-9 months (an entire school year for most kids)
No treatment can mean serious consequences
Increases risk of:
Substance abuse
Eating disorders
Adolescent pregnancy
Suicidal thoughts
More ongoing problems at school/home/friends
Without treatment, the child runs the risk of developing a chronic and more difficult to treat depression
Once a child has one period of depression, they are at greater risk to get depressed again

10. Medications 1st line: SSRIs 2nd line: SNRIs
Prozac (Fluoxetine): >7 for OCD, >8 for MDD
Celexa (Citalopram): >12 for depression
Lexapro (Escitalopram): >12 for depression
Zoloft (Sertraline): >6 for OCD
2nd line: SNRIs
Cymbalta: >7 for GAD
Effexor: off label for anxiety/depression
A lot of meds will be off label!

11. How long to treat?
Per the National Institute of Mental Health study, children and adolescents should stay on their meds for at least 6-9 months AFTER remission
This is to help prevent relapse
Go slowly, closely monitor, and look for signs of relapse
Be more cautious with those who have:
A family history of mood disorders
Severe and complex episodes of depression
A slow and difficult response to treatment
A history of chronic depression
Multiple depressive episodes may benefit from continuing treatment for 1-2 years or more.

12. Screening Tools AAP, APA, or AACAP “sanctioned”
NOT a diagnosis (but they help…A LOT)

13. PHQ-9 Modified for Adolescents
9 symptom inventory of depression
Scoring:
Self-rated
In consideration of the last 14 days
For ages 7-17 consider the CDI (but it will cost $) 5 10 15 20
Mild
Moderate
Moderately Severe
Severe

15. Reimbursement:
96110

16. Genetic Component Depression runs in families
Children with one depressed parent are 3x more likely to have MDD than children of non-depressed parents
In children exposed to substantial stress:
Those with mother’s who were depressed did worse than those with just the stress
We need to treat parents!!!

17. Resources AACAP (American Academy of Child and Adolescent Psychiatry)
DSM-5
NIMH (National Institute of Mental Health)
The Use of Medication in Treating Childhood and Adolescent Depression: Information for Patients and Families - Prepared by the APA and the AACAP in consultation with a National Coalition of Concerned Parents, Providers, and Professional Associations
PHQ9: as endorsed by APA/AAP; Validated by Richardson, et.al.: Evaluation of the Patient Health Questionnaire-9 Item for Detecting Major Depression Among Adolescents. Pediatrics; 2010 Dec; 126(6):

18. THANK YOU!!
Questions?