Sadness

  1. Key Points
    1. Infancy Mood Problems
    2. School Age
      1. Kinds of Sadness Problems
        1. Sadness Variation and Problem
        2. Major Depressive Disorder
          1. Risk Factors
          2. Etiology
          3. Triggers
        3. Adjustment Disorder
        4. Bereavement
        5. Bipolar I and II
        6. Cyclothymic Disorder
  2. Definitions
    1. Variations
    2. Problems
    3. Disorders
  3. Management
    1. Infants
    2. School Age Children
      1. Sadness Variation and Sadness Problem (applies to all Disorders also)
      2. Major Depressive Disorder
      3. Nonmedication Therapies
      4. Medications
      5. Dysthymic Disorder
      6. Bereavement
      7. Bereavement - Recommended Readings
      8. Bipolar I Disorder
  4. Adolescents
    1. Key Points - Adolescence
    2. Making a Diagnosis
    3. Making a Severity/Impairment Estimation
    4. Differential Diagnosis and Comorbidity
    5. Management
  5. Appendices
    1. Recording Procedures: Major Depressive Disorders
    2. Recording Procedures: Adjustment Disorders
    3. Recording Procedures - Bipolar I Disorders
  6. Citations

Key Points

Infancy Mood Problems

School Age

Kinds of Sadness Problems

Sadness Variation and Problem

Prevalence of Disorders Preadolescents Adolescents
Major depressive disorder 2% 5%
Dysthymia 2% 8%
Bipolar disorder 0.3% 1%

Major Depressive Disorder

Important Definitions

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 precious functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
    1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
    2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
    3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease in appetite nearly every day
    4. insomnia /hypersomnia nearly every day
    5. psychomotor agitation or retardation nearly every day
    6. fatigue of loss of energy nearly every day
    7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
    8. diminished ability to think or concentrate, or indecisiveness, nearly every day
    9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  2. The symptoms do not meet criteria for a Mixed Episode.
  3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The symptoms are not better accounted for by Bereavement.

Manic Episode

  1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
  2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood if only irritable) and have been present to a significant degree:
    1. inflated self-esteem or grandiosity
    2. decreased need for sleep
    3. more talkative than usual or pressure to keep talking
    4. flight of ideas or subjective experience that thoughts are racing
    5. distractibility
    6. increase in goal-directed activity
    7. excessive involvement in pleasurable activities that have a high potential for painful consequences
  3. The symptoms do not meet criteria for a Mixed Episode
  4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Mixed Episode

  1. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
  2. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  3. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Hypomanic Episode

  1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
  2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    1. inflated self-esteem or grandiosity
    2. decreased need for sleep
    3. more talkative than usual or pressure to keep talking
    4. flight of ideas or subjective experience that thoughts are racing
    5. distractibility
    6. increase in goal-directed activity or psychomotor agitation
    7. excessive involvement in pleasurable activities that have a high potential for painful consequence
  3. The episode is not associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
  4. The disturbance in mood and the change in functioning are observable by others.
  5. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
  6. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment should not count toward a diagnosis of bipolar II disorder.

Risk Factors

  • personal or family history of depressive disorder (especially mother) increases risk x3
  • anxiety symptoms in childhood
  • prior suicide attempts
  • female gender
  • lack of social supports
  • stressful life events[note]
  • current substance abuse

Triggers

Adjustment Disorder

Bereavement

  • Most children do not develop serious emotional problems after the loss of a parent, but some do
  • Risk factors for adjustment problems:
    • when death was a suicide
    • preexisting psychopathology in child or family
    • families who resolve conflicts poorly
    • poor adjustment in surviving parent
  • Peak of problem symptoms
    • Most 1 month after the death; but 1/3 peaked 6 mos later and 1/6 at one year (Weller, RA 1991)
  • Children who develop persistent sequelae may not show symptoms until one or two years later (Worden JW 1996)

Bipolar I and II

Definitions

According to the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version (Wolraich, M. (Ed.) 1996) , the following are the definitions for Sadness and Bereavement variations and problems:

Variations

V65.49 Sadness Variation

Transient depressive responses or mood to changes in stress are normal in otherwise healthy populations.

Parent text for school age children.

Parent text for preschool children.

Problems

V40.3 Sadness Problem

Sadness or irritability that begins to include some symptoms of Major Depressive Disorders in mild form.

  • depressed/irritable mood
  • diminished interest or pleasure
  • weight loss/gain, or failure to make expected weight gains
  • insomnia/hypersomnia
  • psychomotor agitation/retardation
  • fatigue or energy loss
  • feelings of worthlessness or excessive or inappropriate guilt
  • diminished ability to think/concentrate

However, the behaviors are not sufficiently intense to qualify for a depressive disorder. These symptoms should be more than transient and have a mild impact on the child's functioning. Bereavement that continues beyond 2 months may also be a problem.

Parent text for preschool children.

Parent text for school age children.

Disorders

According to the Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) (American Psychiatric Association 1994) , the following are the definitions for the Major Depressive, Dysthymic, Adjustment, Depressive Not Otherwise Specified, Bipolar I and II, and Cyclothymic Disorders:

296.2x Major Depressive Disorder, Single Episode

Presence of a single Major Depressive Episode. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder. and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.[note]

Specify (for current or most recent episode):

Severity/Psychotic/Remission Specifiers

Chronic

With Catatonic Features

With Atypical Features

With Postpartum Onset

Parent text for preschool children.

Parent text for school age children.d

296.3x Major Depressive Disorder, Recurrent

  1. Presence of two or more Major Depressive Episodes. To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.
  2. The Major Depressive Episodes are not better accounted for by Schizoaffective and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  3. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.[note]

Specify (for current or most recent episodes):

Severity/Psychotic/Remission Specifiers

Chronic

With Catatonic Features

With Melancholic Features

With Atypical Features

With Postpartum Onset

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

Recording Procedures

Recording Procedures, Depressive Disorders

Parent text for preschool children.

Parent text for school age children.

300.4 Dysthymic Disorder

Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.[note]

  1. Presence, while depressed, of two ( or more) of the following:
    1. poor appetite or overeating
    2. insomnia/hypersomnia
    3. low energy or fatigue
    4. low self-esteem
    5. poor concentration or difficulty making decisions
    6. feelings of hopelessness
  2. During the 2-year period (1 year for children or adolescence) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
  3. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or major Depressive Disorder, In Partial Remission.[note]
  4. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for a Cyclothymic Disorder.
  5. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
  6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
  7. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Early Onset: if onset is before age 21 years

Late Onset: if onset is age 21 years or older

Specify (for most recent 2 years of Dysthymic Disorder):

With Atypical Features

Parent text for preschool children.

Parent text for school age children.

309 Adjustment Disorder

  1. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor(s)
  2. These symptoms or behaviors are clinically significant as evidenced by either of the following:
    1. marked distress that is in excess of what would be expected from exposure to the stressor
    2. significant impairment in social or occupational (academic) functioning
  3. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
  4. The symptoms do not represent Bereavement.
  5. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional six months.

Specify if:

Acute: if the disturbance lasts less than 6 months

Chronic: if the disturbance lasts for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The Chronic specifier therefore applies when the duration of the disturbance is longer to a chronic stressor or to a stressor that has enduring consequences.

Recording Procedures - Adjustment Disorders

Parent text for preschool children., Acute

Parent text for preschool children., Chronic

Parent text for school age children., Acute

Parent text for school age children., Chronic

311 Depressive Disorder Not Otherwise Specified

The Depressive Disorder Not Otherwise Specified category includes disorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood. Sometimes depressive symptoms can be present as part of an Anxiety Disorder Not Otherwise Specified. Examples of Depressive Disorder Not Otherwise Specified include:

  1. Premenstrual dysphoric disorder.
  2. Minor depressive disorder
  3. Recurrent brief depressive disorder
  4. Postpsychotic depressive disorder of Schizophrenia
  5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of Schizophrenia.
  6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

Parent text for preschool children.

Parent text for school age children.

V62.82 Bereavement

Sadness related to a major loss. Typically persists for less than 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a major depressive disorder. These include guilt about things other than actions taken or not taken by the survivor at the time of death, thoughts of death, and morbid preoccupation with worthlessness.

Parent text for preschool children.

Parent text for school age children.

296.0x Bipolar I Disorder, Single Manic Episode

  1. Presence of only one Manic Episode and no past Major Depressive Episodes.[note]
  2. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify if:

Mixed: if symptoms meet criteria for a Mixed Episode.

Specify (for current or most recent episode):

Severity/Psychotic/Remission Specifiers

With Catatonic Features

With Postpartum Onset

Parent text for preschool children.

Parent text for school age children.

296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

  1. Currently (or most recently) in a Hypomanic Episode.
  2. There has previously been at least one Manic Episode or Mixed Episode.
  3. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)

With Rapid Cycling

Parent text for preschool children.

Parent text for school age children.

296.4x Bipolar I Disorder, Most Recent Episode Manic

  1. Currently (or most recently) in a Manic Episode
  2. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode.
  3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify (for current or most recent episode):

Severity/Psychotic/Remission Specifiers

With Catatonic Features

With Postpartum Onset

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)

With Rapid Cycling

Parent text for preschool children.

Parent text for school age children.

296.6x Bipolar I Disorder, Most Recent Episode Mixed

  1. Currently (or most recently) in a Mixed Episode.
  2. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode.
  3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify (for current or most recent episode):

Severity/Psychotic/Remission Specifiers

With Catatonic Features

With Postpartum Onset

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)

With Rapid Cycling

Parent text for preschool children.

Parent text for school age children.

296.5x Bipolar I Disorder, Most Recent Episode Depressed

  1. Currently (or most recently) in a Major Depressive Episode.
  2. There has previously been at least one Manic Episode or Mixed Episode.
  3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specify (for current or most recent episode):

Severity/Psychotic/Remission Specifiers

Chronic

With Catatonic Features

With Melancholic Features

With Atypical Features

With Postpartum Onset

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)

With Rapid Cycling

Parent text for preschool children.

Parent text for school age children.

296.7 Bipolar I Disorder, Most Recent Episode Unspecified

  1. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode.
  2. There has previously been at least one Manic Episode or Mixed Episode.
  3. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  5. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)

With Rapid Cycling

Recording Procedures

Parent text for preschool children.

Parent text for school age children.

296.89 Bipolar II Disorder (Recurrent Major Depressive Episodes with Hypomanic Episodes)

  2. Presence (or history) of one or more Major Depressive Episodes.
  3. Presence (or history) of at least one Hypomanic Episode.
  4. There has never been a Manic Episode or a Mixed Episode.
  5. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  6. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify current or most recent episode:

Hypomanic: if currently (or most recently) in a Hypomanic Episode.

Parent text for preschool children.

Parent text for school age children.

Depressed: if currently (or most recently) in a Major Depressive Episode.

Parent text for preschool children.

Parent text for school age children.

Specify (for current or most recent Major Depressive Episode only if it is the most recent type of mood episode):

Severity/Psychotic/Remission Specifiers

Note: Fifth-digit coded cannot be used here because the code for Bipolar II Disorder already uses the fifth digit.

Chronic

With Catatonic Features

With Melancholic Features

With Atypical Features

With Postpartum Onset

Specify:

Longitudinal Course Specifiers (With and Without Interepisode Recovery)

With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)

With Rapid Cycling

296.80 Bipolar Disorder Not Otherwise Specified

The Bipolar Disorder Not Otherwise Specified category includes disorders with bipolar features that do not meet the criteria for any specific Bipolar Disorder. Examples include:

  1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that do not meet minimal duration criteria for a Manic Episode or a Major Depressive Episode.
  2. Recurrent Hypomanic Episodes without intercurrent depressive symptoms.
  3. A Manic or Mixed Episode superimposed on Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Otherwise Specified.
  4. Situations in which the clinician has concluded that a Bipolar Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

Parent text for preschool children.

Parent text for school age children.

301.13 Cyclothymic Disorder

  1. For at least 2 years[note], the presence of numerous periods with Hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode.
  2. During the above 2-year period (1 year in children and adolescents), the person has not been without symptoms in Criterion A for mot than 2 months at a time.
  3. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.[note]
  4. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
  5. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
  6. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Parent text for preschool children.

Parent text for school age children.

Management

Infants

References for this section

School Age Children

Sadness Variation and Sadness Problem (applies to all Disorders also)

Major Depressive Disorder

Nonmedication Therapies

(See also: Nonmedication Alternatives for Your Child pt)

Medications

(See also: Medication Tables in Child Psychopharmacology DTW)

  • The efficacy of medication for treatment of depression in children and adolescents is currently controversial due to review of published and nonpublished data shows:
  • In moderately depressed adolescents with good family support primary care clinicians may use an SSRI especially in context of:
    • Strong family history of depression with good response to medications
    • The adolescent in therapy but depressive symptoms persist
    • The adolescent was previously functioning well but has an acute impairment due to depressive symptoms
  • Watch for emergence of hypomanic/manic symptoms with antidepressant treatment.
  • Tricyclics have been shown to be noneffective in children.
  • SSRI side effects[note]
  • Emphasize appropriate expectations: Depression is a chronic illness and treatments generally take months to work not days or weeks.
  • Note that except for fluoxetine, the SSRIs tend to have a shorter half-life in children and may need a higher dose once they have shown they can tolerate a smaller dose

Dysthymic Disorder

Bereavement

(See: A Parent's Guide to Bereavement pt)

  • Discuss with parents that each child reacts to loss in a unique way and help them to understand their child's reaction.
  • Encourage parents to answer any questions simply and honestly in language the child can understand.
  • If possible help parents prepare a child in advance for the death of a loved one.
  • It is important not to compare death to sleep.[note]
  • Parents can explain death as a time when the body stops working.
  • Help parents be attuned to feelings of guilt that their child may not be able to express.
  • Encourage the use of religious supports when relevant to the family.
  • Talk about ways the parent can provide ongoing opportunities for the child to ask any questions she may have about death.
  • Help parents be honest about their own emotions with their child without losing control.
  • Make parents aware that in children bereavement reactions tend to be milder and of shorter duration in children than adolescents. They should not be disappointed if the young child does not seem to be grieving "an appropriate amount".
  • Funeral attendance (see Funerals pt)
    • Most older children report that attending the funeral and participating in arrangements made it easier for them to accept the loss.
      • If a young child decides to participate a non-grieving adult should be available to play with the child or remove them from the scene if they appear bored or distressed.
  • Consider mental health referral for children with:
    • Personal or family history of psychiatric difficulties
    • History of previous losses
    • Poor social supports
    • Surviving family members who are overwhelmed with their own grief

Bereavement - Recommended Readings

Weller, RA, Weller EB, Fristad MA, et al: Depression in recently bereaved children prepubertal chidren AmJ Psychiatry 2: 418: 1536-1540, 1991.

Worden JW: Children and Grief: When a Parent Dies. New York, Guilford. 1996

Bipolar I Disorder

  • Referral to a mental health provider is indicated for initial evaluation and treatment
  • Provide support and advice to the family for dealing with the daily stress of the child's behavior. (See: Reducing Your Child's Daily Stress pt)
  • Provide educational materials to parents (Consider: The Bipolar Child, Bipolar Disorders - A Guide to Helping Children and Adolescents)
  • Assure adequate sleep as sleep debt can precipitate manic episodes. (See: The Importance of Sleep pt)
  • Mood stabilizers used for prophylaxis and acute treatment of mania or depression.
  • Start with mood stabilizers then add antidepressants to avoid mania.
  • Valproate and carbamazepine are better than Lithium for rapid cyclers or mixed.
  • Lithium
    • Requires levels, assessment of kidney function (although renal effects are rare).
    • Check for hypothyroidism every 4-6 months.
    • Side effects[note]
    • Avoid during first trimester - causes Ebstein's anomaly in fetus.
  • Neuroleptics
    • Mainly for initial stabilization of manic, agitated and psychotic patients or when can't increase Lithium dose.
    • Long-term danger of tardive dyskinesia.
    • Fewer side effects[note] with Risperdal, olanzapine, and Abilify Benzodiazepines, e.g. clonazepam may be used temporarily

Adolescents

Adapted from GLAD-PC* (Guidelines for Adolescent Depression in Primary Care Rachel Zuckerbrot Ed with permission. Edits for CHADIS by Raymond Sturner and Amy Cheung)

Key Points - Adolescence

Epidemiology

Identification

Communicate with teens and parents:

  1. De-stigmatize the experience of being depressed.
  2. Educate the patient and family about the:
    • Origins
      Depression probably results from an innate predisposition coupled with recent stressors
    • Time course:
      1. Treated depression will likely result in return to regular functioning in weeks or months.
      2. Without treatment, depression may last many months or years and is likely to recur.
    • Treatment options for depression.
  3. Empower the patient and family to get the help they need.

Making a Diagnosis

Clinical Guide Algorithm

  1. Establish Confidentiality: Must be discussed with teen and parents including its limits when the risk of harm to the adolescent or others may be imminent.
  2. Using Standardized depression tools: Assess based on diagnostic criteria, (i. e.), established in the DSM IV (See: Definitions) such as spelled out by CHADIS-DSM tool or other standardized tools.
  3. Probe for the presence of any of several depressive disorders, including MDD, Dysthymia, and Depression NOS using systematic, rigorous assessment methods.
    • Direct interview (Piacentini, J 1993) , (Cox, A 1981) , (Cox, A 1981) of the adolescent separate from others: Standardized instruments should be used but not replace interviews since adolescents with depression may not be able to clearly identify depressed mood as their presenting complaint.
    • Ask about common presenting symptoms: Insomnia, weight loss, decline in academic functioning, family conflict, as well as other symptoms of depressive disorders (Ryan, ND 1987) .
    • Distinquish transient depressive responses from depressive disorders. The DSM-PC defines these levels of severity (Wolraich, M. (Ed.) 1996) (as assessed through CHADIS-DSM) can help distinguish between transient depressive responses and depressive disorders.
    • Direct interviews with families/caregivers separate from youth
      • Family is critical for management and should be included from the beginning.
      • Elicit report of symptoms of depression and functional impairment (Costello, EJ 1996) , (Jensen, PS 1999)
      • Family relationships may also impact on the presentation
      • Cultural background can impact the presentation of core symptoms (Manson SM 1985) .
      • Consider use of CHADIS-DSM for parents and PHQ-A for teen if not already completed.

Making a Severity/Impairment Estimation

Assess for impairment in: school, home, and peer settings (Curry, J 2006) . Subjective distress should also be assessed.

Severity is judged by the numbers of the 9 MDD symptoms & reported impairment as noted below:

DSM-IV Guidelines for Grading Severity Depression
Category Mild Moderate Severe
Number (of 9 MDD) symptoms 5-6* * "most"
Severity of symptoms Mild * Severe
Degree of functional impairment** Mild impairment or normal functioning but with "substantial and unusual" effort * "Clear-cut, observable disability"
According to the DSM-IV-TR, Moderate episodes of depression "have a severity that is intermediate between mild and severe."
*Except consider severe even with "mild" in symptoms if: risk factors: presenting with of a specific suicide plan
or recent attempt;
psychotic symptoms;
family history of first degree relatives with bipolar disorder, or severe impairment in functioning (such as unable to leave home).
**Impairment > number of symptoms so:
Severe = >6 >/=mild depressive symptoms & severe impairment

Differential Diagnosis and Comorbidity

Differential Diagnosis for Depressive Disorders

Comorbidity with Depressive Disorders (See: Clinical Guide Algorithm)

Management

Clinical Guide Algorithm

General approach - Groundwork in the practice

Treatment

First Priority = Safety Assessment and Planning

Educate and counsel families and patients about depression and options for the management of the disorder.

Treatment options for depression

Develop specific treatment plan

General Principles:

Treatment Options - based in part on severity assessment (See: Severity/Impairment Estimation)

New onset Mild

  • If improvement at predetermined period of time- continue active monitoring awhile longer
  • If no improvement or worsens, treatment with evidence based therapies (antidepressants or psychotherapy - see below) should be offered.
  • If refuse other treatments, continue active support and monitoring

    • Mild Depression with moderate or severe or comorbidities such as substance abuse, recommend treatment, crisis intervention (as indicated), and mental health consultation immediately without a period of active monitoring.

    Moderate depression with or without comorbid anxiety, consider consultation by mental health and/or treatment in the PC setting.

    Severe: Referrals and Follow-up

    Sequence in Referral Process

    1. Recognizes need for mental health referral.
    2. Explains reasons for mental health referral and recommends appropriate level of care and type of mental health services (i.e. inpatient, outpatient; counselor, psychologist, psychiatrist).
    3. Determine patient and family agreement for outside care:
      • If patient and family do not agree to seek help from a mental health specialist, clinician and/or office staff provides education, support and counseling, and reinforces the need for mental health referral.
      • If patient and family are amenable selected MHP based upon a variety of factors, such as geographic location, insurance coverage, goals of treatment, and if combined therapy with antidepressants are being used. (See Provider Search in CHADIS Resource Database)
    4. Complete the referral form (See PCP to MHP form), once a MHP is chosen, including PCP office contact information to facilitate further communication and follow up. Send form or form can be given to MHP directly by the patient and his/her parent or guardian.
    5. Consider providing the MHP with a Release of Information and Report form (See Release of Information form), so he/she can communicate basic impressions and recommendations to PCP This form was designed to be HIPAA-compliant, but should be vetted by your practice's quality assurance representative before official use.
    6. PCP and MHP together, should:

    Treatment Choices: Supportive Counseling & Problem-Focused Therapy

    Problem Solving Treatments for Primary Care (PST-PC)

    Evidence-based Psychotherapy

    Two "brands" of psychotherapy have been shown to be helpful for youth depression (see Table below):

    Components of both CBT and IPT-A can usefully be included by experienced clinicians although they are designed to be given by highly-trained therapists as a "package".

    Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT)
    Therapy Key Components Manuals/Websites
    CBT -Thoughts influence behaviors and feelings, and vice versa. Certain negative thoughts, such as pessimism and self-denigration, evoke negative feelings that predispose to and/or are exacerbated in depression. Treatment targets patient's thoughts and behaviors to improve his/her mood.

    -Essential elements of CBT include increasing pleasurable activities (behavioral activation), reducing negative thoughts (cognitive restructuring), and improving assertiveness and problem-solving skills to reduce feelings of hopelessness    		 TREATING DEPRESSED CHILDREN: THERAPIST MANUAL FOR "TAKING ACTION" Kevin Stark, Ph.D., and Philip C. Kendall, Ph.D., 1996 53pp., $13.00

    ADOLESCENT COPING WITH DEPRESSION COURSE Gregory Clarke, Ph.D. Peter Lewinsohn, PhD Hyman Hops, Ph.D. ©1990 www.Kpchr.org
    IPT -Interpersonal problems may cause or exacerbate depression and that depression, in turn, may exacerbate interpersonal problems. Treatment targets patient's interpersonal problems to improve both interpersonal functioning and his/her mood.

    -Essential elements of interpersonal therapy include identifying an interpersonal problem area, improving interpersonal problem-solving skills, and modifying communication patterns.    		 Interpersonal Psychotherapy for Depressed Adolescents, 2nd ed.

    Laura Mufson, Kristen Pollack Dorta, Donna Moreau, and Myrna M. Weissman. New York, Guilford Publications, 2004, 315 pp., $36.00.

    CBT=Cognitive Behavioral Therapy
    IPT=Interpersonal Therapy

    Evidence-based Pharmacotherapy

    When to consider medication:

    Before prescribing, assure:

    Points to cover with parents and children are:

    Medication Effectiveness Data

    Selective Serotonin Reuptake Inhibitors (SSRIs)

    Monitor for adverse events

    Ongoing Management

    Systematic and regular tracking of goals and outcomes from treatment

    Follow-up visit should be within 1 week of start of meds.

    Content at every visit should ask about:

    Finding the optimal dose

    Dosing is adequate when:

    Increase dosage when:

    Assess for side effects at each dose

    Side effects of SSRI's:

    Common

    • Dry mouth
    • Constipation
    • Diarrhea
    • Sweating
    • Sleep disturbance
    • Sexual dysfunction
    • Irritability
    • "Disinhibition" (risk-taking behaviors, increased impulsivity, or doing things that the youth might not otherwise do)
    • Agitation or jitteriness
    • Headache
    • Appetite changes
    • Rashes

    More serious side effects include the following:

    • Serotonin syndrome (fever, hyperthermia, restlessness, confusion, etc.)
    • Akathisia
    • Hypomania
    • Discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache)
    SSRI Titration Schedule
    SSRI Starting Dose* Increments Max Daily Dose Contra-indicated Meds Available Doses RCT evidence for efficacy Generic available
    Fluoxetine (Prozac) 10mg qd/od** 10-20mg 60mg MAOIs 10 mg tablets
    10,20,40 mg pulvules
    90mg weekly pulvule and liquid form    		 Y*** Y
    Sertaline (Zoloft) 25mg qd/od** 12.5-25mg 200mg MAOIs 25, 50, 100 mg tablets and liquid form Y N
    Citalopram (Celexa) 10mg qd/od** 10mg 60mg MAOIs 20, 40 mg tablets and liquid form Y Y
    Escitalopram (Lexapro) 5mg qd/od** 5mg 20mg MAOIs 5, 10, 20 mg tablets and liquid form N N
    Fluvoxamine (Luvox) 25 mg qd/od, ** then bid 25 mg 250mg MAOI's, terfenadine, astemizole, pimozide 25, 50, 100 mg tablets and liquid form N Y
    * Start with lower doses for younger children; **qd = od = every day; ***Fluoxetine is FDA approved.
    FIRST LINE medications are Fluoxetine, Sertaline, and Citalopram.
    SECOND LINE medications are Escitalopram, and Fluvoxamine.

    Changing Medication

    Medication Tapering Increments Time between each taper
    Fluoxetine 10 mg 1-2 weeks
    Sertraline 25 mg 1-2 weeks
    Citalopram 10 mg 1-2 weeks
    Escitalopram 5 mg 1-2 weeks
    Fluvoxamine 50 mg 1-2 weeks
    Paroxetine 5 mg 1-2 weeks

    *May start second medication but need to inform patients/families about possible adverse events such as serotonin syndrome

    If no improvement after 6-8 weeks

    If partial improvement

    Maintaining Medication

    In order to maintain medication the following is recommended:

    Stopping Medication

    When discontinuing medication, taper medication slowly. All SSRIs, with the exception of fluoxetine, should be slowly tapered when discontinued due to risk of withdrawal effects. See above table.

    After stopping medication for depression

    Suicidality in Adolescents and the Black Box Warning, (Adapted from the APA / AACAP's PhysiciansMedGuide)

    Suicidality in Adolescents: Suicidal ideation and suicide attempts are common in adolescence and do not have the same prognostic significance for completed suicide as those behaviors in later life. Quoting data from the Youth Risk Behavior Study, the federal Centers for Disease Prevention and Control (CDC), reports that 17% of adolescents think about suicide in a given year. Among high school students, 12% of girls and 5% of boys attempt suicide in a given year. (Available at http://www.cdc.gov/HealthyYouth/YRBS/pdfs/trends-suicide.pdf. Accessed 12/29/2004) Ultimately, 2 per 100,000 girls and 12 per 100,000 boys die as a result of such attempts - a ratio of attempts to completed suicides is 6,000 to 1 among girls and 400 to 1 among boys. In the U.S., this translates into approximately 2000 young people who die each year as a result of suicide. Fortunately, however, the overall rate of suicide in the 10-19 year age range has declined by 25% over the past decade. Since this decade has been associated with a dramatic increase in the prescription rates of the newer SSRI antidepressants, a recent study has demonstrated that a 1% increase in prescription of antidepressant medication was associated with a 0.23 per 100,000 decrease in adolescent suicides. (Olfson M, Shaffer D, Marcus SC, Greenberg T. (2003). Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 60:978-982.)

    The Black Box Warning: In 2004, the FDA reviewed detailed reports of 23 clinical trials involving more than 4,400 children and adolescents who had been prescribed any of nine antidepressants for treatment of major depression, anxiety, or obsessive-compulsive disorder. (T.A. Hammad. Results of the Analysis of Suicidality in Pediatric Trials of Newer Antidepressants. Presentation at the FDA Center for Drug Evaluation and Research (CDER), Bethesda, MD. September 13, 2004. Available at: www.fda.gov/ohrms/dockets/ac/cder04.html#PsychopharmacologidDrugs. Accessed January 5, 2005.) No suicides occurred in any of these trials. The FDA concluded that more of the children and teens who were receiving an antidepressant medication spontaneously reported that they thought about suicide or made a suicide attempt than did those who received a placebo. At the same time, systematic measures of suicidality were available from 17 of the 23 studies. The FDA's analysis of these data found that medication did not increase suicidality that had been present at the start of the study, and that it did not induce new suicidality in those without prior suicidal ideation.In fact, all studies showed a reduction in suicidality over the course of treatment.

    The FDA's analysis showed that about 2 out of 100 children not taking medication would spontaneously report suicidal thoughts and/or behaviors, compared to 4 out of 100 who were taking medication. These rates need to be understood in the context of findings from community samples cited previously in which as many as half or more of teenagers with major depression are thinking about suicide at the time of diagnosis and some 16% to 35% have made a previous suicide attempt. Although only nine medications were re-examined in the analysis, the FDA applied the labeling changes to all antidepressant medications. This was done on the basis of the advisory committee's concern that applying the warning only to the newer antidepressants reviewed would give doctors and patients the false impression that older antidepressants such as TCAs had a more favorable risk-benefit ratio.

    Appendices

    Recording Procedures: Major Depressive Disorders

    The diagnostic codes for Major Depressive Disorder (Single Episode and Recurrent) are selected as follows:

    1. The first three digits are 296.
    2. The fourth digit is either 2 (if there is only a single Major Depressive Episode) or 3 (if there are recurrent Major Depressive Episodes).
    3. The fifth digit indicates the following: 1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features, 5 for In Partial Remission, 6 for In Full Remission, and 0 if Unspecified, Other specifiers for Major Depressive Disorder cannot be coded.

    In recording the name of a diagnosis, terms should be listed in the following order: Major Depressive Disorder, specifiers coded in the fourth digit (e.g., Recurrent), specifiers coded in the fifth digit (e.g., Mild, Severe with Psychotic Features, In Partial Remission, as many specifiers (without codes) as apply to the most recent episode (e.g., With Melancholic Features, With Postpartum Onset), and as many specifiers (without codes) as apply to the course of episodes (e.g., With full Interepisode Recovery); for example, 296.32 Major Depressive Disorder, Recurrent, Moderate, With Atypical Features, With Seasonal Pattern, With Full Interepisode Recovery.

    Recording Procedures: Adjustment Disorders

    Adjustment Disorders are coded according to the subtype that best characterizes the predominant symptoms:

    1. 309.0 With Depressed Mood: when the predominant manifestations are symptoms such as depressed mood, tearfulness, or feelings of hopelessness.
    2. 309.24 With Anxiety: when the predominant manifestations are symptoms such as nervousness, worry, or jitteriness or, in children, fears of separation from major attachment figures.
    3. 309.28 With Mixed Anxiety and Depressed Mood: when the predominant manifestation is a combination of depression and anxiety.
    4. 309.29 With Disturbance of Conduct: when the predominant manifestation is a disturbance in conduct in which there is a violation of the rights of others or of major age-appropriate societal norms and rules (e.g., truancy, vandalism, reckless driving, fighting, defaulting on legal responsibilities)
    5. 309.30 With Mixed Disturbance of Emotions and Conduct: when the predominant manifestations are both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct (see above subtype)
    6. 309.31 Unspecified: for maladaptive reactions (e.g., physical complaints, social withdrawal, or work in academic inhibition) to psychological stressors that are not classifiable as one of the specific subtypes of Adjustment disorder.

    Coding Note: In a multiaxial assessment, the nature of the stressor can be indicated by listing it on Axis IV (e.g., Divorce)

    Recording Procedures - Bipolar I Disorders

    The diagnostic codes for Bipolar I Disorder are selected as follows:

    1. The first three digits are 296
    2. The fourth digit is 0 if there is a single Manic Episode. For recurrent episodes, the fourth digit is 4 if the current or most recent episode is a Hypomanic Episode or a Manic Episode, 6 if it is a Mixed Episode, 5 if it is a Major Depressive Episode, and 7 if the current or most recent episode is Unspecified.
    3. The fifth digit (except for Bipolar I Disorder, Most Recent Episode Hypomanic, and Bipolar I Disorder, Most Recent Episode Unspecified) indicates the following: 1 for Mild Severity, 2 for Moderate Severity, 3 for Severe without Psychotic Features, 4 for Severe with Psychotic Features, 5 for In Partial Remission, 6 for In Full Remission, and 0 if Unspecified. Other specifiers for Bipolar I Disorder cannot be coded. For Bipolar I Disorder, Most Recent Episode, Hypomanic, the fifth digit is always 0. For Bipolar Disorder, Most Recent Episode Unspecified, there is no fifth digit.

    In recording the name of the diagnosis, terms should be listed in the following order: Bipolar I Disorder, specifiers coded in the fourth digit (e.g., Mild, Severe with Psychotic Features, In Partial Remission), as many specifiers (without codes) as apply to the most recent episode (e.g., With Melancholic Features, With Postpartum Onset), and as many specifiers (without codes) as apply to the course of episodes (e.g., With rapid Cycling); for example, 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, With Melancholic Features, With Rapid Cycling.

    Note that if the single episode of Bipolar I Disorder is a Mixed Episode, the diagnosis would be indicated as 296.0x Bipolar I Disorder, Single Manic Episode, Mixed.

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