Asking questions about suicide does not increase the risk that a person will attempt suicide.
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MAJOR
depression is
common in children
and adolescents, with
a prevalence of about
2% in children, rising to 4-8% in
adolescents.
By the age of 18 years, about
20% of adolescents will have had
an episode of major depression.
Equally as common in pre-pubertal
boys and girls, by adolescence
depression is twice as common
among girls.
It has extensive co-morbidity,
with 40-90% of depressed adoles
cents also having another mental
health disorder such as anxiety,
behaviour problems or substance-
use disorder. If left untreated,
major depression may affect a
child
s emotional, cognitive and
social development and impair
family and peer relationships.
A milder form of depression,
dysthymic disorder, is as common
as major depression. Up to 70%
of affected children will eventually
develop an episode of major
depression, so diagnosing and
treating dysthymia is also impor
tant.
Many depressed children and
teenagers will present to their
family doctor with somatic or
other emotional symptoms. This
may account for the fact that
depression goes unrecognised in up
to two-thirds of teenagers with the
condition.
Actively asking about depressive
symptoms in patients at risk is
therefore important.
Risk factors for depression in
children and adolescents include:
A personal or family history of
depression, bipolar disorder or
suicide attempts.
Co-existing psychiatric disorder
or substance abuse.
A history of psychological
trauma.
Other psychosocial problems such
as a family crisis.
Clinical features
Clinical features of major depres
sion are compared with those of
dysthymia in Table 1 (see
below
Children and adolescents often
present with irritability rather than
depression per se. This is true for
both major depression and dys
thymic disorder.
Dysthymia is often overlooked
in children and adolescents because
it presents with fewer symptoms
than major depression, so it is
important to consider this diagno
sis in any child presenting with
long-standing irritability.
Asking the right questions
A useful way of screening children
and adolescents who may be expe
riencing depression is to use a
rating scale such as the CES-DC
scale (see
Resources
box,
below
or the Columbia Depression Scale
(available in the GLAD-PC Toolkit
—
see
Resources
box). Such self-
rating scales are an effective and
efficient way of identifying those
at risk, as well as being useful in
monitoring the effects of treatment.
Children and teenagers should
be interviewed individually as well
as with their caregivers, because
this provides an opportunity to
obtain information that the child
or teenager may be unwilling to
disclose in front of parents. Talking
to teachers can provide additional
information.
Assessing the child
s level of dis
tress or impairment is an impor
tant aspect of making a diagnosis
and planning for treatment.
Inquiries should be made about the
major areas of functioning
home, school and peer relation
ships.
A complete assessment also
requires attention to current family
circumstances and to other psy
chosocial issues facing the child.
Difficulties in family relation
ships are recognised as important
in the development of depression,
poor response to treatment and
recurrence of depression. Daily
stresses, major life events and lack
of peer support have a similar
effect.
Determining suicide risk
It is important to assess for suicide
risk. Asking questions about sui
cide does not increase the risk that
a person will attempt suicide.
Rather, it communicates a willing
ness to listen and help.
Effective management of suicide
risk can only occur if the right
questions are asked. Questions
about suicide can be gently intro
duced, for example in a sequence
such as:
Have you felt that life is
not worth living?
Have you had
any thoughts about harming your
self?
; leading to
Have you thought
about suicide?
and
Have you ever
attempted suicide?
If the young person is thinking of
suicide, it is appropriate to ask
whether they have considered how
they would attempt it (to assess for
potential lethality), what has
stopped them so far, whether they
have a specific plan, whether the
means is available to them, and if
they have made any prepara
tions, such as obtaining tablets.
Severity
With an understanding of the
symptoms that are present
and an assessment of the level
of distress, impairment and
risk, it is possible to determine
the severity of the depression.
Mild depression will be
characterised by 5-6 symp
toms that are mild and have
minimal impact on daily func
tioning. The depression rating
scales will have low scores.
In contrast, severe depres
sion will meet most or all of
the diagnostic criteria and give
high scores on rating scales. If
any of the following features
are present, the depressive
episode should be considered
severe:
Psychotic symptoms.
Severe impairment of func
tioning.
A suicide plan or clear intent.
A history of a recent suicide
attempt.
Moderate depression falls
between these two extremes.
Management
Management of depression in
the general practice setting
should begin with education
for both children and their
families about the nature of
the illness and management
options. This needs to include
a frank discussion about the
limits of confidentiality, espe
cially the need to inform
family members or child pro
tection authorities when there
is risk of harm to the child or
teenager.
Involving families and the
child in management decisions
creates a strong treatment
alliance and helps in setting
goals for the major areas of
functioning (home, school and
peer relationships).
Advising on lifestyle mea
sures, including the impor
tance of a regular exercise
program and healthy eating,
can be a useful adjunct to
treatment.
Addressing psychosocial
issues or referring the child
and family for counselling for
these problems can be
extremely helpful in the man
agement of depression.
Given that many children
and teenagers will require spe
cialised mental health assis
tance, developing links
between GPs and available
mental health resources is also
helpful.
This can be difficult, but a
co-ordinated approach to the
depressed child
s care is of
paramount importance.
A safety management plan
is also essential
when managing depression.
This needs to include supervi
sion by a responsible adult
and the removal of lethal
means of suicide. An emer
gency contact plan
for
example with a local crisis
team
must also be put in
place.
Teenagers should also be
warned that illicit drugs or
alcohol may have a disinhibit
ing effect, which may increase
the risk of suicide attempts
while intoxicated. They
should also be told that sub
stance use may worsen their
symptoms of depression.
It is important to develop
the safety plan along with the
depressed child or teenager
and their caregiver and to
arrange a follow-up appoint
ment in the short term. Hos
pital admission should be con
sidered if the child
s safety is
of concern.
In mild depression, provid
ing support and education
about the disorder and moni
toring the condition is associ
ated with improvement for
many children and teenagers.
However, in moderate or
severe depression, or where
there are complicating factors
such as substance abuse or
psychosis, active management
is required and GPs should
also consider referral to a
mental health specialist.
Medication and psychological approaches
Recent research on the treat
ment of moderate-to-severe
major depression in adoles
cents recommends the combi
nation of cognitive behaviour
therapy (CBT) and fluoxetine,
because this works more effec
tively than either treatment
alone.
CBT may also help prevent
suicidal events. Interpersonal
psychotherapy has also been
shown to be effective in the
treatment of adolescents with
depression.
Establishing referral path
ways to psychologists and
psychiatrists with these thera
peutic skills will help GPs to
provide comprehensive man
agement plans for young
people with depression.
While there have been con
cerns about an increase in sui
cide risk associated with
SSRIs, more recent research
indicates that this risk is lower
than originally reported.
There is now evidence of the
efficacy of antidepressants for
children and teenagers with
major depression.
Adolescents tend to re
spond better to antidepres
sants than children. In chil
dren younger than 12,
fluoxetine is the only antide
pressant that shows a greater
therapeutic effect than
placebo, but it should be
noted that children have high
rates of response to treatment
with placebo.
In contrast to SSRIs, tri
cyclic antidepressants should
be avoided in children
younger than 12. They are no
better than placebo in this age
group, are associated with
more side effects than SSRIs
and can be fatal in overdose.
Because efficacy of antide
pressant medications is
inversely proportional to
duration of depression, early
identification and treatment
may improve outcome for
depressed young people.
It is important to inform
children and caregivers about
the common side effects of
medication, especially events
such as switch to mania, agi
tation or suicidal behaviour.
Also, medication must be
be given an adequate trial. In
general, starting with fluoxe
tine 10mg a day, increasing
to 20mg a day and continuing
this dose for at least four
weeks before further dose
increases are appropriate.
Monitoring for side effects
and clinical response should
occur at least weekly for the
first four weeks, then second
weekly for four weeks, at 12
weeks, and then as clinically
indicated. Treatment should
continue for 6-12 months
after recovery to reduce the
risk of relapse.
Conclusion
GPs play an important role in
the identification and effective
management of depression in
children and adolescents. Pre
vention of serious morbidity
has important implications for
ongoing development in this
age group.
Table 1: Clinical features of major depression and dysthymia
DEPRESSION
Symptoms:
At least five of the symptoms listed; at least one of those in bold is essential.
•Depressed mood (or irritable mood in children and adolescents) for most of the day almost every day
•Lack of interest or pleasure in almost all usual activities
Changed appetite, with weight loss or gain (or lack of expected weight gain in children)
Sleep changes (hypersomnia or insomnia)
Agitation or psychomotor retardation
Lack of energy
Feelings of worthlessness or guilt
Poor concentration
Thoughts of death or suicide
Duration:
> Two weeks
Common age-specific features:
Children: Physical complaints, irritability and social withdrawal. Adolescents: Psychomotor retardation, increased sleep and delusions
DYSTHYMIA
Symptoms:
At least three of the symptoms listed; those in bold are essential.
•Depressed mood (or irritable mood in children and adolescents) for most of the day almost every day
Changed appetite, with weight loss or gain (or lack of expected weight gain in children)
Sleep changes (can be increased or decreased)
Lack of energy
Low self-esteem
Poor concentration
Feelings of hopelessness
Duration:
> One year
Common age-specific features:
Children and adolescents: Irritable mood, poor self-esteem, poor social skills and pessimism
RESOURCES:
CES-DC scale for screening for depression
www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf (accessed 24 June 2008).
Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit
www.glad-pc.org/documents/GLAD-PCToolkit.pdf
Mood Gym
http://moodgym.anu.edu.au/welcome
Youth Beyond Blue
www2.youthbeyondblue.com/ybblue/
Dr Bowden is director oftraining, child and adolescentpsychiatry, NSW Institute ofPsychiatry; senior staffspecialist child and adolescentpsychiatrist, Children’sHospital at Westmead; clinicallecturer, departments ofpsychological medicine andchild health, Western ClinicalSchool, University of Sydney.
References available on request.