Childhood depression

one of the most neglected topic in pediatrics which is actually common. These slides will help u to recognise a child who is in depression.

1. CHILDHOOD DEPRESSION DR C ABHIRAM KUMAR PG PEDIATRICS

2. INTRODUCTION CLASSIFICATION ETILOGY CLINICAL FEATURES ASSESSMENT DIFFERENTIAL DIAGNOSIS TREATMENT OVERVIEW

3. Depression in childhood was once thought to be rare relatively harmless and responsive to even minor treatment It is now clear that childhood depression has potential for being a far more serious illness than once thought The point prevalence of childhood depression i s 0.5-2% in preadolescents and 2-8% in adolescents INTRODUCTION

4. Depressive disorders in children and adolescents have significant impact on youth’s social, cognitive and emotional development Early onset depression is associated with more lifetime depressive episodes and suicidal behavior than late onset depression Early recognition is essential so that children may receive effective evidence based treatment INTRODUCTION

5. The DSM-5 includes the following in category of depressive disorders: Major depressive disorder Persistent depressive disorder (dysthymia) Disruptive mood dysregulation disorder Premenstrual dysphoric disorder Depressive disorder due to another medical condition Other specified and unspecified depressive disorders CLASSIFICATION

6. Genetic Neurobiological Environmental Cognitive distortion and rumination Fear and anxiety Comorbid medical illness ETIOLOGY

7. 7 G enetic N eurobiological E nvironmental D epression

8. amygdala striatum p refrontal cortex

9. neural remodelling Developmental events and gender Environment ( s tressors, life events) Genes depressive episode

10. Criteria for major depressive disorder in children and adolescents according to DSM5 are at least one major depressive episode in which there has been at least a 2 week period of either depressed or irritable mood or a loss of interest or pleasure In addition at least four of the following symptoms are required to call it as a major depressive disorder CLINICAL FEATURES

11. Significant weight loss or gain(5% change in 1month) Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive guilt Inability to think or concentrate or indecisiveness Recurrent thoughts of death, suicidal ideation, suicidal attempt or suicide plan

12. The symptoms cause significant impairment in social, occupational or other areas of functioning There has never been a manic or hypomanic episode The episode is not attributable to physiological effects of a substance or other medical condition

13. Persistent depressive disorder in children and adolescents is a chronically depressed or irritable mood for at least 1year During the one year period one must not have had depressive free symptoms for more than two months at a time In addition at least two of the following symptoms must be present during the depressive episode

14. Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self esteem Poor concentration or difficulty in making decisions Feelings of hopelessness

15. Disruptive mood dysregulation disorder is characterized by recurrent verbal or behavioral temporal outbursts( ≥3/week) In between the episodes child is irritable or angry most of the day nearly every day Symptoms must be present in at least two settings(school, home or with peers)

16. The duration of symptoms must be more than 12 months, without a 3 months symptom free period during this time frame Age of onset must be before 10 years old and diagnosis must not be made before the age of 6 years and after the age of 18 years

17. Other specified or unspecified depressive disorder applies to presentation in which symptoms are characteristic of depressive disorder and also cause significant impairment These disorders however donot meet the full criteria for any of the disorders in this diagnostic class

18. Depression is diagnosed if the child’s symptoms fulfill the diagnostic criteria in DSM 5 Laboratory investigations for anemia, hypothyroidism can be done if they are suspected to be the cause for depression The Child’s Depression Rating Scale can be used to screen in a suspected case of depression ASSESSMENT

19. Bipolar disorder Adjustment disorder Anxiety disorders Attention deficit hyperactivity disorder Autism spectrum disorder Drugs Medical conditions DIFFERENTIAL DIAGNOSIS

20. Determine level of care Develop a safety plan Diagnostic assessment, comorbid conditions and setting treatment priorities Rule out medical contributors to depression Psychosocial stressors leading to treatment resistance Match patient to available treatment CLINICAL APPROACH

21. Treatment can be divided into three stages Acute treatment (first 2-8 weeks) Consolidation (2-6 months) Continuation ( 6- 12 months) TREATMENT

22. The goal of acute treatment is to achieve response which is defined as at least 50% decline in depressive symptoms and a global rating of improved or very much improved Consolidation involves either continuation of the same treatment or adjusting t he treatment to address residual symptoms to achieve remission

23. Treatment for mild depression in absence of major risk factors is guided self help with watchful waiting This includes provision of education materials to youth for dealing with stressful situations Advice to parents about strengthening parent child relationship Modifying adverse e nvironmental exposures During this period additional follow ups should be scheduled

24. Treatment for moderate to severe depression includes psychotherapy or antidepressant medication or a combination of both Evidence based psychotherapy for treating depression include cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as monotherapies

25. Cognitive Behavioral Therapy focuses on identifying cognitive distortions that may lead to depressed mood and correcting them It also teaches problem solving, behavior activation, social communication and emotional regulation skills to combat depression It is approximately for 8-16 sessions

26. Interpersonal Psychotherapy c onceptualizes depression as seeing related to loss, role conflict and interpersonal discord This therapy helps individuals decrease interpersonal conflicts by teaching problem solving skills They help to modify dysfunctional communication and relational patterns It is delivered in a set o f 10-16 sessions

27. Pharmacological treatment: Selective Seretonin Reuptake Inhibitors are the only antidepressants that have been efficacious in controlling childhood depression Only Fluoxetine and Escitalopram have been approved by the FDA for treatment of childhood depression Fluoxetine is the only drug for preadolescent depression and both of the above can be used for adolescent depression

28. Fluoxetine can be started with 5 to 10mg and gradually increased to 20mg/day depending on the response Most common side effects are GI disturbances, headache, tiredness Some studies show that there has been increase in suicidal ideation after use of Flluoxetine

29. For moderate depression monotherapy with CBT, IPT or antidepressant medication can be used For severe depression SSRI medication with psychotherapy is preferred Residual symptoms such as sleep disturbances, anhedonia , irritability may be present despite therapy Rule out medical conditions and possible contribution of comorbid conditions

30. Patient not responding to any of the above therapies is considered to be resistant to treatment Any comorbid conditions, psychosocial stressors not previously addressed to must be ruled out before labeling as treatment resistant TREATMENT RESISTANT DEPRESSION

31. Various options to be considered: Switching to a second SSRI with CBT Switch to a 3 rd class even if no response to the 2 nd one Augmentation with antipsychotic, lithium or bupropion if partial response to an SSRI Electroconvulsive Therapy

32. Childhood depression is a chronic and disabling disorder It needs expertise to diagnose childhood depression due to myriad of symptoms It is associated with many comorbid conditions Early diagnosis is necessary for early intervention to prevent morbidity CONCLUSION

33. Psychotherapy in the form of cognitive behavior therapy and interpersonal therapy have been effective for treating moderate depression Fluoxetine for >8 years and Escitalopram for >12 years are the only approved drugs for treatment of childhood depression Combined psychotherapy and pharmacotherapy have proven to be more effective in treating severe depression than either of them alone

34. Kaplan & Sadock’s comprehensive textbook of psychiatry, 10 th edition Rutter’s child and adolescent psychiatry, 6 th edition Nelson textbook of pediatrics, 20 th edition Practical child psychiatry: The clinician’s guide Child and adolescent psychiatry- a comprehensive textbook by Melwin Lewis, 3 rd edition Understanding childhood depression review article by Savita Malhotra and Partha Pratim Das REFERENCES

35. THANKYOU