Major Depressive Disorder in children and
adolescents (MDD)
Prof. Debbie van der Westhuizen
Head: Child- and Adolescent Units
Weskoppies Hospital
Nobody loves me
Overall, the clinical picture and diagnosis of MDD in children
is similar to that in adults: using DSM-IV-TR criteria
However, a few differences in clinical
description exist
• Due to child’s psychosocial developmental stage
• Children tend to be more irritable and have more low
frustration tolerance, temper tantrums, failure to make
expected weight gains, somatic complaints, hallucinations,
social withdrawal instead of verbalizing feelings of
depression when compared to adolescents;
• Adolescents usually have more melancholic symptoms
and suicide attempts
Subtypes of MDD: prognostic & treatment
implications
• MDD with psychotic features: associated with family
history of bipolar- and psychotic depression; more severe
depression; greater long-term morbidity, resistance to
antidepressant mono-therapy and an increased risk of
bipolar disorder
• MDD can manifest with atypical symptoms such as
increased reactivity to rejection, lethargy, (leaded
paralysis), increased appetite, craving for carbohydrates,
and hyper-somnia
Subtypes of MDD: prognostic & treatment
implications
• Youth with seasonal affective disorder where symptoms of
depression are mainly during the season with less daylight
should be differentiated from depression being triggered
by school stress
• Less intense than MDD is dysthymic disorder (DD); a
more chronic depression (1 year); often overlooked and
misdiagnosed; consists of long-term change in mood;
causing more psychosocial impairment
Why should childhood depressive disorders
be early identified and treated ?
• Major depression (MDD) and dysthymia (DD) are
familial, recurrent, associated with significant
psychosocial morbidity (school drop-outs,
substance abuse) and mortality (suicide)
What is your role as GP?
• No biological tests are available that guide diagnosis and
treatment of depressed youth
• Diagnosis is based on a comprehensive evaluation with
the child and other informants; parents, teachers and aftercare
• Taking history with main complaint and MSE (mental
status evaluation) should elicit specific signs and
symptoms supported by decline in academic,
interpersonal, self-care and hobbies
• Academic performance: barometer for mental health
What do we know about epidemiology?
• Prevalence of MDD is 2% in children and 8% in
adolescence; 10% suffer from sub-syndromal symptoms
• Single most predictive risk factor for MDD is high family
loading; heritability of MDD is 60% (Cradock et al, 2005)
What do we know about risk factors and clinical
description?
• Genes predispose to react to stressful negative situations
with depressive symptoms
• Aetiology of MDD seems to be determined by interaction
of certain:
1.Genes 2.environment (support) 3.cognitive-, 4.coping style
What do we know about risk factors and clinical
description?
Stressors
Support
• Onset and recurrences of MDD may be precipitated by:
losses, abuse neglect, ongoing conflicts, exposure to
violence, and frustrations
• Effects of stress depend on cognitive- & coping styles
(rumination and hopelessness), IQ, socio-economic- and
family support
Diagnostic criteria for MDD
A. Depressed mood and or lost of pleasure/interest for most
of the day or subjective change from previous functioning
during same 2-week period; children and adolescents
irritable mood
B. 1. depressed mood or subjective reports (feels sad and empty) or only
irritable
2. marked diminished interest or pleasure in almost all daily activities
most of the day
3. significant weight loss(when not dieting) or failure to make expected
weight gains
4. insomnia or hypersomnia nearly every day
Diagnostic criteria for MDD
A. Depressed mood and or lost of pleasure/interest for most
of the day or subjective change from previous functioning
during same 2-week period; children and adolescents
irritable mood:
B. 5. psychomotor agitation- or retardation
6. fatigue or loss of energy
7. feelings of worthlessness
8. diminished ability to think or concentrate
9. recurrent thoughts of death, recurrent suicidal ideation
Diagnostic criteria for MDD
C. Symptoms do not meet criteria for mixed
episode
D. Symptoms cause clinically distress (social,
school)
E. Not due to direct psychological effects of a
substance, other drug or medication or GMC
F. Symptoms not better accounted for by
bereavement
Co-morbidity
• MDD and DD may occur together (so called “double
depression”) and either can be accompanied by medical
or neurological illness
Depressive disorder co-morbidity
• 40-90% of youth have other psychiatric disorders
• Up to 50% having two or more co-morbid diagnosis
1st Anxiety
disorders
2nd
Disruptive
behaviour
disorders
3rd ADHD,
substance
use
disorders
Prevention of onset- or recurrence of
depression
• Improve risk factors such as sub-syndromal symptoms of
depression, underlying psychiatric disorders (anxiety-),
ongoing stressful situations, parental psychopathology,
marital discord, substance abuse; treat depressed moms
early and vigorously
• Stop the cruel cycle of: depression; that makes child
irritable;- increases interpersonal conflict; other distance
themselves from depressed child; loneliness and lack of
support worsens
• Successful treatment of mothers with depression; fewer
new diagnoses and remission rates
• Maternal depression associated with less response to CBT
The cruel bidirectional relationship of stress,
conflict & depression
Stress- others
distance
themselves,
more lonely
Interpersonal
conflict
increases
Depression
makes child
irritable
Clinical course and outcome
• Median duration of MDD in clinically referred youth is 8
months; although recover from 1st episode; recurrences
60% by 1-2 years after remission and up to 70% after 5
years; continue to have MDD episodes as adults
• Childhood depression (DD); protracted course, mean
episode length 3-4 years; increased risk for MDD; other
behaviour disorder and substance abuse; impulsivity,
aggression, exposure to negative life events (early
pregnancy) 20-40% develop bipolar disorder
• If untreated, negative emotional, cognitive and social skills
that interfere with family relationships; suicide attempts
and completed suicide
Be aware of the following when taking
history
• Comprehensive evaluation includes thorough knowledge of specific
developmental stages of children and adolescents, sex, race,
environmental conditions, cultural- and religious background
Race
Child’s
developmental
stage
Culturalbackground
Sex
Environmental
conditions
Religiousbackground
Psych
evaluation
Evaluation: History + MSE
Exclude pregnancy
(females), HIV, STDs
substance abuse: ucannabis, party
screen on blood,
effects of steroids
Exclude general
medical conditions:
hypothyroidism,
mononucleosis,
anemia, cancer,
autoimmune, premenstrual dysphoric
disorder
Co-morbid psychiatric
conditions; psychosis;
reactions to
bereavement and
other stressors
Knowledge of signs
and symptoms of
MDD in children and
adolescents
Evaluate suicidal- selfharm-, homicidal risk;
with child & parents;
and need for
hospitalization
Instruments
• Standardized structured and semi-structured interviews are available
for evaluation psychiatric symptoms in children > 7 years
• Typically too long to use in non-research settings
• Use a mood diary and mood timeline in the assessment of onset and
course of mood disorders; use school years and birthdays as anchors
• Mood is rated from very happy (10) to very sad (0) or irritable to nonirritable.
• Also note normative-, non-normative stressors and treatments
• Parent and child self-report instruments or clinician-based scales:
CDRS (Children’s Depression Rating Scale) to assess severity of
depression before, during and after treatment
Three treatment phases
• Main goal: to achieve response and ultimately full symptomatic
remission
• Divided in 3 phases: acute, continuation, and maintenance
• Choice of treatment: age, cognitive development, severity and subtype
of depression, chronicity, co-morbid conditions, family-, psychiatric
history, family- and social environment, preferences, culture, religion,
expertise in pharmacology available, and/or psychotherapy
Treatment phases: achieve response and ultimately
full symptomatic remission
Acute: to achieve
response
Continuation:
consolidate
response, avoid
relapses
Maintenance: to
avoid recurrences
or new episodes
Frequent follow-ups during treatment
• Frequent contacts with parents
• Sufficient time to monitor clinical status: symptoms of
depression, suicide ideation, development of mania or
hypomania, co-morbid disorders
• Treatment response is the absence of MDD or significant
reduction in symptom severity (50%)
• The goal is to restore function and not to reduce
symptoms;-lack in progress in functioning is a clue that
depression is incompletely treated; or due to a co-morbid
psychiatric- medical disorder or environmental factor
Psycho education and adherence to medication
• Evaluate presence of side-effects/explain possible sideeffects that may contribute to poor compliance or early
discontinuation
• Establish child and parent’s belief about medication
benefit
• History of suicidal/homicidal ideation or somatic symptoms
before starting
• Safety: parents to lock away medication and give daily
dosages under supervision
Psycho education (PE): supportive management for
parents & school
Parent
counselling &
training,
support
groups
Improves
families of
depressed
parents ability
to solve
problems
Educate
family and
school about
depression
Advocate
school to
accommodate
child until
better;
workload
Collaborate
parent, child,
teachers as
part of MDT
Acute treatment: psychotherapy
• CBT, and IPT (interpersonal therapy) have evidence of
efficacy from RCT’s (specific depressed adolescents)
• Overall effect of psychotherapy for acute treatment of
depressed youth are modest
• CBT is effective in MDD; can be delivered effectively at
PHC settings
• However, in history of sexual abuse or depressed parents,
CBT is not so effective
Acute treatment: pharmacotherapy
• Efficacy: Fluoxetine showed a larger difference between
medication and placebo than other antidepressants (long
half life may lessen the effect of poor adherence), or
studies better designed including more severe depressed
patients
• Optimal pharmacological treatment may involve higher
dose or longer duration treatment, the lack of treatment of
co-morbid conditions, some children need to receive a
combination of pharmacological and psychosocial
interventions
• Findings from the TADS (Treatment for
Adolescents with Depression) indicate:
fluoxetine is superior to placebo for the
treatment of depression in youth but is not
associated with greater decreases in
suicidal ideation
• All groups exhibit a significant decrease in
suicidal ideation34
Anti-depressants in Children and
adolescents
• US FDA’s meta-analysis of short-term
placebo-controlled trails of SSRIs and other
antidepressants in youth indicated:
increased risk of suicide ideation or attempt
• Suicidality occurred early in treatment and
consisted of increased or new-onset
suicidal ideation, with very few suicide
attempts and no suicide completions.
• A recent meta-analysis supports the assertion that
many more youth will show a good clinical
response to SSRIs than will become suicidal
• Side-effects: may trigger rarely hypomania in
predispose child, or worsening or onset of
suicidal ideation/attempt (more so in venlafaxine)
• No suicide completions were reported
Tips for describing antidepressants
• Inform the patient and the family about the risks and
benefits of selective serotonin reuptake inhibitors; discuss
black box warning
• Be sure to inform family members specifically about the
risk of suicide behaviour
• Therapy should be started at a low dose (equivalent of 510mg of fluoxetine)
• If needed, dose increases should be considered every 2
weeks
• The food and Drug Administration recommends weekly
monitoring for the first 4 weeks of antidepressant therapy
and after dose adjustment
Common warning signs for
adolescent suicide
• Sudden change in behaviour
• Apathy
• Withdrawal
• Change in eating patterns
• Unusual preoccupation with death or dying
• The giving away of valued personal possessions
• Signs of depression
• Moodiness
• Hopelessness
Continuation phase:
• Monthly follow-up (depending on clinical status)
• Assess: functioning (academic & interpersonal), support
systems, environmental stressors, motivation for
treatment, presence of co-morbid psychiatric and medical
conditions
• Assess internal; as well as external conflicts that may
result in relapse
• If taking antidepressants, continue to foster adherence,
optimize dose, evaluate for side effects
Maintenance treatment
MDD+DD, subsyndromal
symptoms of
depression,
other
psychiatric or
medical
conditions,
psychosis
Asymptomatic
for 6-12
months: which
therapy and
how long
>2 episodes of
depression or
severe chronic
depression for
one year or
longer
Availability of
physician
suicidality,
past or ongoing
stressors
(abuse,
divorce,
conflicts)
Use of antidepressants
Dosages
similar to
adults,
weekly visits
first 4 w
Clinical
response 4-6
weeks
Youth with
MDD; monitor
for suicide,
mania in
+family
Start low
dose,
increase
slowly, taper
slowly
SSRIs;
shorter halflives; once
daily
withdrawal
Case: Everything bothers her
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

Sally is a 13-year old eight grader who lives
with her parents and her bother
Chief complaint: Sally is "feeling really low
and irritable due to trouble with her friends”
History of present illness: Sally reports that
she has been feeling down since her 7th
grade, after having a big fight with her best
friend
History of present illness


Eventually they reconciled
but Sally felt insecure in
her relationships
When school started the
next year she was worried
that whether they would
like her


She started to struggle in
school during the
semester; falling behind;
her home work required
more time and effort
She began to have
difficulty falling asleep at
night, worried about
school and friends
History

Difficulty to get out
of bed, tired,
stomachaches,
bigger appetite,
craving sweets and
junk food;
increased isolation,
falling grades,
sleep schedule

PHCP explained
she had a
depression; by the
time she was taking
20mg Prozac
(started on 5-10mg
daily) her mood had
brightened and
worries had been
decreasing
History

Although Prozac was

increased to 40mg daily
with weekly supportive
psychotherapy, she still
experienced social
problems, low self-esteem
and attention and gained
weight after months
Sally had a tough time starting
school: worried about her
parents forgetting to pick her up
at school, being shy with peers
No contributing developmental
problems, delivered 38 weeks c
'section

No contributing
psychiatric: learning-,
disruptive disorders;
obsessive compulsive
disorder, substance use
disorder, personality or
medical problems, not
sexually active, good
understanding of the risk
of STD


Family history: MDD in
Sally's mother, father, and
sibling
Socially: family moved
several times (dad's job),
enrolled at small private
school for individual
attention, sibling conflict
younger brother
Mental Status Examination




Sally presented as casually dressed, mildly
overweight youngster, co-operative with
interview
Her speech was normal in rate, tone and
volume
Her psycho-motor status was marked by
considerable fidgeting
Described her own mood as “good”
MSE

Sally's affect was euthymic

Her thoughts were logical and goal directed



No evidence of thought blocking, insertion or deletion, or
ideas of reference
Sally's thought content was remarkable for themes noted
above
No perceptual abnormalities, sensorium clear, cognitive
functions grossly intact, insight preserved, denied current
suicidality/homocidality
Screening Questionnaires



Sally and her parents filled out a set a rating scales in
advance of their visit. On the Children's Depression
Inventory (CDI; Kovacs 1985), Sally endorsed items
indicating negative self-esteem and interpersonal conflict
On the Conner's Teaching Rating Scale the teacher
endorsed items indicating ADHD
ADHD symptoms also endorsed by her parents rating on
Conner's Parenting Rating Scale -Revised (Conner's et
al. 1998)
Commentaries: Psychotherapeutic
Perspective



Diagnostic formulation: Diagnoses to rule out for Sally are
major depressive disorder, dysthymia, social anxiety, and
/or generalized anxiety and ADHD
Fairly clear symptoms of MDD: predominant depressive
mood, feeling down since 7th grade, anhedonia, social
withdrawal, increase in appetite, difficulty falling asleep,
diminished ability to think and concentrate, feelings of
fatigue/low energy;
Fidgeting during interview (psyho-motor agitation)might
be evidence of MDD or ADHD
Assessment



Self-report scales such as the Beck Depression Inventory
(Beck et al 1986) or administered CDI are useful for
screening and for gauging therapy progress, but have
limited usefulness as diagnostic tools
Adult respondent instruments such as the Child Behavior
Checklist (Achenbach and Edelbrock 1983) or Conners'
Teacher/Parent Rating Scales have similar advantages
and drawbacks
My primary diagnostic information would come from a
clinical interview to gauge the presence, the severity
(Impairing) and duration of the symptoms of the
provisional diagnoses
Psychopharmacologic
perspective

Prior history of primarily separation and social anxiety

Beginning in the 7th grade a minor depression



Multiple characteristics that makes this adolescent a risk
for depression: family history of depression, co-morbid
conditions (anxiety, ADHD, minor depression)
During 8th grade she had a MDD treated with SSRIs and
supportive therapy resulting in partial remission of her
depression
Illustrates the importance of accurate diagnoses,
interaction of co-morbid disorders, cause and
consequences of illness, need for rational, evidencebased approach to treatment
Psychopharmacologic treatment

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

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Primary disorder: Depression
Treatment guidelines and algorithms for depression-,
anxiety disorders and ADHD are available
Well-established physician-patient-family relationship
SSRI for MDD, medication management: side-effects like
apathy, sleep disturbance, or appetite changes- versus
ongoing worsening of symptoms of MDD versus
insufficient treatment
For adolescents: 2 adequate trails of an SSRI, switch to
non-SSRI or augment with lithium or bupropion
Co-morbid condition (ADHD)



Clinician should consider treatment of
ADHD, using ADHD treatment guidelines
Using the most effective treatment being a
stimulant
The question is which treatment to initiate
first; if one initiates one intervention at a
time- ADHD or depression?
Continuation treatment




Recommended continuation treatment for depression is
6-9 months
During continuation therapy aggressive treatment of
residual symptoms is recommended because of an
increased chance of relapse
Treatment of residual symptoms: pharmacological plus
CBT or IPT
Accurate diagnosis and assessment are essential,
treatment should be rational, systematic, sequential,
integrating different modalities to optimize outcome
Integrative perspective


Medical approach: Sally meets the DSM-IV-TR diagnostic
criteria for MDD
MDD symptoms have been present for 6 months;
prominent mood symptoms include a depressed mood
most of the day; an irritable mood when stressed or
provoked; prominent neurovegetative symptoms include
weight gain, insomnia, diminished ability to think or
concentrate, fatigue; experiencing the symptoms at home,
school and with peers
Depression and anxiety interact


Diagnostic interview also establishes that
Sally meets criteria for anxiety disorder
NOS- she is intolerant of being alone and
when she feels anxious she tries to relief
emotional stress by excessive social
interaction with friends by “harassing” them
and driving them away; which in turn drives
isolation
Lastly, she meets criteria for previously
undiagnosed ADHD
Treatment recommendations


Built around the need for additional
assessments, recommendations for
psychosocial interventions, medication
management, and both educational- and
behavioral interventions in school
Importantly, interventions of choice are
explicitly evidence-based
Psychotherapy




Empirical literature strongly suggests that Sally will do
best if symptom picture is skillfully addressed using
proven psycho-social interventions; tightly linked to their
target symptoms
The therapist in this model functions as a coach or mentor
to implement a treatment that operates both at
psychological level and on the somatic substrate: CBT
(cognitive restructuring and conflict reduction) for
depression and anxiety management training (exposure,
cognitive restructuring, positive reinforcement)
Participate in social activities (drama club or sport)
Parent management training to modify negative
reinforcement
Medications




Unlikely to make any significant progress
even with skillful CBT without psychopharmaco-therapy
Careful attention to time response and
dose-response
A trail of atomoxetine for ADHD
(medication should cover both depression
and anxiety);
Facilitate the implementation of CBT
Academic performance


Sally was doing well at school; work has
been more challenging because of her poor
attention
With permission of her family, therapist
should update the school about her
treatment so teachers will be aware and
might help with cognitive-behavioral
interventions
Major depressive disorder and death of
a loved one
• Death of significant other or close family member:
• Assess the grieving parent to determine whether he/she
has adequately coped with the loss of the wife/husband
and can adequately deal with son’s grief
• If adolescent is suffering from MDD and complicated
bereavement; started with SSRI and psychotherapy
• Depressed children start with self-medication (drugs)
• Suicidal ideation/ attempts are generally rare among
children with uncomplicated bereavement but may occur
as a feature of complicated bereavement
The End

Any questions?