Doctor Interview
| An interview with Dr. Philip John "Depression in Children and Adolescents" |
Ans. If I have to refer to major depressive illness in children, this assumption of increasing incidence cannot yet be substantiated. However, depression that occurs in the context of psychosocial stressors and interpersonal relationships is increasing exponentially among adolescents. So is the number of children seeking psychiatric help for behavior and mood disorders.
Clinically categorizing the various behavior and mood disorders in children and adolescents can be a tall order, given the overlap of these symptoms in this age group; this difficulty is substantial when you consider depressive disorders.
As regards the causes for this overwhelming morbidity in children today, the rapidity of changes in our family and psychosocial matrix seems to be a major reason. Our failure to teach children ‘Life Skills’ to cope with these changes is a related reason. Their inability to cope with academic frustrations, interpersonal strains, family and career conflicts as well as our increasingly negative cognitive style of “Learnt helplessness” add to the spiraling incidence of depression.
An interesting observation is that the age of onset of major depression has decreased, often attributed to the ‘cohort-effect’ when a genetic disorder tends to worsen in successive generations – thus increasing the figures for children.
In the urban communities of our country and in states like Kerala, the psychosocial factors seem to operate even more. Setting unduly high materialistic targets and aspirations for children results in easy frustration and consequent depression. Today, there is an alarming rise in the number of children attempting suicide. Not surprisingly, in contrast to adults, psychiatric ‘disorders’ are less associated with these attempts. Inadequate ‘Life Skills’ once again emerge as the culprit. In short, the rapid psychosocial changes contribute to the major causes.
Q2. Do you think that depression in children and adolescents goes unnoticed many times?Ans. Oh, yes, for many of us including professionals, enduring mood-disorders are not even meant to occur in childhood! Most of us are on a perpetual quest to discover parenting deficits or environmental excuses for a child’s change of behavior, thus overlooking enduring morbidity like depression!
There are several reasons for this, other than personal bias. Children who display acute mood change are quickly identified; on the other hand, children presenting with prolonged sadness or irritability are overlooked or misdiagnosed. Though the core features of depression remain constant across all developmental periods, children may present with non-descript symptoms, or co-morbidity, which may ‘mask’ the depression.
Our experience at Cochin has shown that multiple psychiatric diagnosis co-exist with childhood depression, making it difficult to ‘palpate’ the depression. Poor School Performance (PSP) is the most usual presentation, along with ADHD, oppositional or defiant behaviour, school refusal etc.
Unlike the adult population, somatic complaints set up a major ‘mask’ for depression in children. Inhibition of play, fatigue, lack of involvement in activities, avoidance of peers etc. also tend to get attributed to various physical symptoms, and the underlying depression gets overlooked. Some depressed adolescents may present with only fatigue or pervasive anhedonia; many others express depression as irritability, aggression or sibling rivalry and we promptly miss their anguish of depression.
However, when they are assessed directly and openly on parameters for enduring mood disorders, children of all ages meet the criteria – for major depression, that is.
Q3. While diagnosing depression in these patients, which are the key questions to be asked?Ans. To firmly diagnose depression, a sagacious examination for core symptoms of depression (which are the same across life span) should reveal at least five depressive symptoms as in adults. These do constitute the key questions.
Developmental level affects the ‘expression’ of mood, for example, irritable mood rather than pervasive anhedonia or psychomotor retardation may be seen in children, in contrast to adults.
It should be made sure that the ‘core depressive symptoms’, whether evolved gradually or imposed on an already dysthymic child, represents a ‘change’ in the child’s behaviour, and that the new symptoms have been persistent for at least two weeks.
Feeling sad, appearing sad, somatic complaints attributable to a depressive phase, apathy to play and peers, irritability, oppositional or conduct disturbances of recent onset etc. are the key questions. In addition, I would also consider changes in concentration, sleep, appetite and routine activities.
Auditory hallucinations and somatic presentations are reported to be greater in prepubertal children, whereas delusions and psychomotor retardation may appear more in adolescents. Suicidality as a pure symptom of depression is considered to be constant across all ages in depression.
Q4. How can we differentiate between primary and secondary depression in children and adolescents?Ans. Differentiating depression into these distinct compartments may be a difficult clinical proposition because of the varied manifestation of this disorder in children. This classification is further complicated by the usual association, in children, with one or more co-morbid psychiatric disorders along with depression. It is also estimated that 50% of children with chronic school refusal and separation anxiety disorder meet all the criteria for major depression. One can, therefore, imagine the difficulties in categorizing children with mood disorders.
However, the temporal association with psychosocial adverse events that precipitate depression can be easily determined. The presence of vegetative signs may be a useful indicator. Psychiatric risk factors like genetic and family risk must be carefully evaluated. The mode of onset and course of the symptoms can reveal an enduring syndrome of primary depression. The extent of distress and functional impairment can also be an indicator.
Guilt, suicidality, hopelessness etc. also serve to differentiate various types of depression. Mood-congruent hallucinations, delusions, psychomotor retardation, withdrawal and pervasive anhedonia when present, certainly indicate the more serious disorder.
It is also important to clinically distinguish between depression as the primary psychiatric disorder, and a number of other behaviour and anxiety disorders on which depression may be superimposed in children.
Q5. Can a depressive disorder in children be related to abnormalities in specific brain system?Ans. Abnormalities in specific brain systems are invariably related to depression, the mind being generated by the brain. As in adults, we expect core neuro-biological processes to dysfunction in depression, but cannot definitely pinpoint the specific biological abnormalities responsible for the various subsets of depression, endogenous or non-endogenous.
As regards your question on specific brain systems, the critical role of nor epinephrine and serotonin in the pathophysiology of mood disorders remains paramount, although the early biogenic amine theories are undergoing much revision. The other important monoamine – dopamine, is also implicated in some subtypes of depression.
It must be remembered that the implication of single, specific neurotransmitters in psychiatric disorders has given way now to ‘functional neural circuits’, neurobehavioral systems and more intricate and complex neuro-regulatory mechanisms like post synaptic receptor families, pre-synaptic auto receptors and hetero-receptors, second messengers, gene-transcription factors etc. So, where do we stand!
It is all the more difficult to define specific systems involved in depression in children, because the early age of onset significantly distorts the personality development itself of the child; it also derails the ‘coping skills’, making such children stumble into disproportionately greater number of stressors. This interplay of personality and psychosocial factors may indicate depression running a more chronic course, with perhaps a lesser role for the primary neuro-biological systems.
Nevertheless, with the current state of understanding, it is prudent to conclude that subsets of depressed children manifest one or more abnormalities of monoamine neuro transmission. Decreased central nor-epinephrine activity can be inferred, as a response to prolonged stress-activation in a depressed child. This potentially leads to ‘learnt helplessness’, anhedonia, anergia and vegetative symptoms.
There is, of course, overwhelming evidence that dysregulation of the serotonin system contributes to the development of depression and suicidality. Dopamine dysregulation may impair the child’s motivation, concentration, cognitive tasks and motor activity and contribute to the development of delusions or hallucinations.
Q6. What are the different options for treating depression in children and adolescents?Ans. The approach to treatment must be bio-psycho-social. In children, the management plan must also consider the absence or presence of co-morbid Developmental, Behavioral, Conduct or Emotional disorders - which too need to be concurrently treated. It has to be emphasized that the emergence of major depression in a child increases the risk of an additional co-morbid psychiatric diagnosis ten to twenty fold!
That considered, the treatment options should include Psychopharmacotherapy and Psychosocial interventions. Cognitive behavioral therapy, interpersonal therapy and family-centred psycho-educational management are significant options in the context of a child or adolescent.
Pharamacotherapy: It needs to be admitted that the choice of antidepressants is indeterminate. The presence of co-morbid disorders in children affects the validation of drug-efficacy studies. Therefore, safer adverse-effect profile becomes a determining factor in the choice of the antidepressant.
Selective serotonin reuptake inhibitors (SSRI) are the mainstay of treatment at present striking an optimum balance between, efficacy and safety, even in children as young as six years. History of seizures and any significant co-morbid medical illnesses need to be ruled out before starting the drug. SSRI s do differ so much from each other on the ground, and the choice of an SSRI in a particular child must depend on the current symptom-profile, age and co-morbidity in the patient, possible effect on the related neurotransmitters, and the adverse-effect profile. This judgment needs to be based on individual experience. Fluoxetine, sertraline, fluvoxamine have been used widely. My experience with paroxetine, citalopram as well as SNRIs in children is too limited for any comment on their efficacy.
Conventional tricyclic drugs, though quite potent adults, are not among first-choice antidepressants for children and adolescents. (I have had only limited experience with your dothiepin in children).
The newer classes of antidepressants that I use prominently include. Bupropion as it also has stimulant properties, trivial anticholinergic effects and does not produce sleepiness. Its stimulant effect can be put to therapeutic use for cases that have ADHD as co-morbidity. It is effective, and does not precipitate Mania. I have not used venlafaxine and mirtazepine in children much.
Psychotic symptoms do call for the use of low doses of antipsychotics like olanzapine or risperidone.
Psychosocial interventions play a significant role along with pharmacotherapy, as an integral part of the comprehensive, multidisciplinary management strategy.
Q7. How do we calculate / titrate the dose of antidepressants in these patients?Ans. The thumb-rule in depression is to treat it ‘adequately’-using adequate dose, for adequate duration. Clinical discretion is the guideline for the choice of the antidepressant, as well as its dosage in each given patient; the judicious determination of the dosages of (one or more) drugs may not be based on calculations. Constant monitoring of the response and side-effects as the treatment progresses will help decide on the dosage.
For children, I often start half the (non-geriatric) adult starting-dose of the antidepressant, and titrate upward based on clinical response and tolerance of adverse effects. The upward titration may be in increments of ¼ of total intended dose, every 3-4 days. Once the patient is symptom-free, I prefer to wait on that dose for at least six (6) months and then taper to ½ the dose for further 3 months before stopping the drug. The patient needs to be on regular follow-up.
Q8. Does depression in children and adolescents require a long-term management?Ans. Depression and dysthymia do call for long-term management. Several long–term follow-up studies have shown that major depression in children is a ‘serious, relapsing disorder with lingering social impairment and a later risk of suicide’. Mood disorders take a ‘long and tortuous course’ in children – some studies show a mean episode length of 32 months.
The earlier the age at diagnosis, the more protracted the recovery. Management is ‘prolonged and tortuous’ in the presence of co-morbid ADHD, conduct disorder and obsessive illnesses; it is also longer if there is development of mania and consequent diagnosis of bipolar illness.
The general guideline is to treat the depression with pharmacotherapy adequately enough for recovery, and then wait till the child is symptom-free for six continuous months before beginning to taper off. Concurrent psychosocial, multidisciplinary management may be necessary to remedy cognitive, academic and residual social impairment.
Q9. Which are the risk factors for the recurrence of a depressive episode in these patients?Ans. Children diagnosed with major depression are at a higher risk than adults for recurrence, due to factors that make them more vulnerable. It is estimated that there is a 72% risk of relapse for children diagnosed with major depression, and that two thirds of children with dysthymic disorder have a major depression within 5 years of diagnosis ("double depression"). Treatment duration is also based on the fact that the risk of recurrence is highest within the first one year after recovery. In general, the severity of the index episode and the presence of psychotic symptoms increase the risk of recurrence.
Specifically, ‘low self-esteem’ in children plays a significant role in precipitating recurrences. This negative cognitive style, coupled with co-morbidity like Learning disorders, ADHD or other disruptive disorders seems to increase the recurrence risk. Obsessive children, less flexible children (“less flexible for generating solutions”) are vulnerable for depressive episodes or suicidality with each adverse life event. Genetic and environmental factors too enhance risk of relapse or recurrence.
Q10. Which are the risk factors for the recurrence of a depressive episode in these patients?Ans. To be frank, I am not aware of a support group working specifically in this area. Adhoc support during adverse events (as examinations!) is made available for children by NGOs working in the field of suicide prevention in various urban locations, especially in Kerala. These are mostly ‘Helplines’.
Interventional Support Group for adolescents is an excellent idea worth chasing, especially in these times when the family unit is disintegrating. Such support groups need to carefully design programmes for our school children and adolescents to enhance their self-esteem and Life-Skills to prevent and to combat depression.
