019 - Depression in Children and Adolescents

This Episode covers major depressive disorder in children and adolescents.  According to the American Board of Psychiatry and Neurology, content related to depressive disorders constitute 7 to 9 percent of the board exam, so it’s worth a second, third and even fourth look.  Again, I will leave you in the competent hands of my AI co-hosts, Algernon and Alisa, or Allen and Alberta.  They don’t care what you call them, just call them maybe.

Referenced resources can be found within the show transcripts at https://psydactic_caps.buzzsprout.com

Feedback can be emailed to feedback@psydactic.com OR submitted via a form at https://psydactic.com.

This is not medical advice. Please see a licensed physician for any personal questions regarding your own or your child's health.

Transcript

Depression in Children and Adolescents

Resources used to generate content:

https://doi.org/10.1001/jama.2022.16946?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jama.2022.16946.

Abright, Arthur Reese, and Eugene Grudnikoff. 2020. “Measurement-Based Care in the Treatment of Adolescent Depression.” Child and Adolescent Psychiatric Clinics of North America 29 (4): 631–43.

Ayvaci, Emine Rabia, and Paul E. Croarkin. 2023. “Special Populations: Treatment-Resistant Depression in Children and Adolescents.” The Psychiatric Clinics of North America 46 (2): 359–70.

Bernaras, Elena, Joana Jaureguizar, and Maite Garaigordobil. 2019. “Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments.” Frontiers in Psychology 10 (March): 543.

“Depression in Children - StatPearls - NCBI Bookshelf.” n.d.

Meyer, Allison E., and John F. Curry. 2021. “Moderators of Treatment for Adolescent Depression.” Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 50 (4): 486–97.

Słopień, A. 1965. “Depression in Children and Adolescents.” European Psychiatry: The Journal of the Association of European Psychiatrists 7 (December): 1–2.

Thapar, Anita, Olga Eyre, Vikram Patel, and David Brent. 2022. “Depression in Young People.” Lancet 400 (10352): 617–31.

Viswanathan, Meera, Sara M. Kennedy, Joni McKeeman, Robert Christian, Manny Coker-Schwimmer, Jennifer Cook Middleton, Carla Bann, Linda Lux, Charli Randolph, and Valerie Forman-Hoffman. 2020. “Treatment of Depression in Children and Adolescents.” RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center. https://doi.org/10.23970/ahrqepccer224.

Weersing, V. Robin, Pauline Goger, Karen T. G. Schwartz, Selena A. Baca, Felix Angulo, and Merissa Kado-Walton. 2025. “Evidence-Base Update of Psychosocial and Combination Treatments for Child and Adolescent Depression.” Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 54 (1): 1–51.

Welcome to PsyDactic - Child and Adolescent Psychiatry Edition.  Today is Monday, March 31, 2025.  I am your host, Dr. O'Leary, a child and adolescent psychiatry fellow in the national capital region.  This is a podcast I designed to help myself and other Child and Adolescent Psychiatry fellows study for their boards.  Anyone interested in human development and mental health will likely also get something out of it.  I am using AI to assist me with the content creation.  The tool that I used to create this episode allows me to feed it papers I found during a literature search of peer reviewed and reputable sources.  Then I create a prompt to guide the discussion.  I usually have to create 2-3 different prompts and explore the output of each, fact check it, then pick the best parts, edit out problem parts, and paste it all together.  Even though I am using AI, all the content in the podcast should be considered my opinion and no one else's.  At the very least, it is compiled by me and released to you, so I take editorial responsibility for that. If you find errors in the content or have suggestions for improvement, I would love it if you could go to PsyDactic.Com and fill out a form there to let me know.  You can also email me at feedback@psydactic.com. 

Today’s Episode covers major depressive disorder in children and adolescents.  According to the American Board of Psychiatry and Neurology, content related to depressive disorders constitute 7 to 9 percent of the board exam, so it’s worth a second, third and even fourth look.  So, let me leave you in the competent hands of my AI co-hosts, Algernon and Allisa, or Allen and Alberta.  They don’t care what you call them, just call them maybe.

We're tackling a pretty heavy but really, really important topic. Depression in well, kids and teens.

Yeah, youth mental health. It's a It's a big one. A lot of folks are trying to makeense of it all.

It is. And that's what we're hoping to do today. You know, cut through the noise, really distill what matters most. And let's be real, this isn't just a small segment of the population we're talking about.

No, not at all. And the thing is, when depression in young people, kids and teens, goes unressed. The repercussions, well, they can be devastating.

Absolutely. You're talking about a higher chance of depression popping up again in adulthood, a greater risk of developing other mental health issues, and of course, the most heartbreaking consequence of all.

Yeah. The increase risk of suicidal thoughts, suicide attempts, and well, tragically, suicide completion. It's a harsh reality. Suicide being the second leading cause of death for those aged 10 to 19. And you know, for young people with existing psychiatric conditions or those who've attempted suicide before, that risk, it just it skyrockets.

It's a stark reminder of why this is such a critical issue to address. So, today in our deep dive, we're laser focused on extracting the most vital information, the real nuts and bolts of how depression is diagnosed in kids and teens, what treatments have the official FDA stamp of approval, and how important therapy is both on its own and in conjunction with medication. We've poured over systematic reviews, clinical practice guidelines, whole bunch of research studies, basically to bring you the essential knowledge without, you know, bogging you down with too much information.

Right. Right.

So, first things first, diagnosis. What's the prevalence of depression among young people? Give us the lay of the land.

Okay. So, when we talk about major depressive disorder or MDD, we see that about 2% of children experience it. Now, in adolescence, that rate, it jumps up like significantly between 4% and 8%.

Wow, that's a big jump.

Yeah, it is. I would just like to hop in here and point out that there are a lot of different numbers talking about the prevalence of depression in children and adolescence. And it seems to depend a lot on how you define depression, what cutoff you use, even where you do your study. So, Take these numbers with a grain of salt. Although they are generally accurate in terms of their magnitude and directions of change.

Now another interesting thing is that during childhood the ratio of boys to girls who experience MDD is pretty even like one.

Okay.

But once puberty hits there's a shift. It becomes more like one boy for every two girls.

Huh. That's fascinating. Why do you think that is?

You know it really suggests that there's this complex interplay between well hormonal changes that happen during puberty and the societal pressures especially on girls.

Yeah.

That could contribute to the development of depression.

And another thing, you know, we've even seen MDD in preschoolers.

Really that young?

Yep. Although those episodes might not always meet the full two week duration that the DSM5 requires for a diagnosis.

Okay, that makes sense. So, what about the overall picture? As kids grow up, you know, head towards adulthood. What are the numbers like then?

By the time they reach 18, about 20% of young people in community samples have experienced MDD. It's a pretty substantial portion of the population. And it's not just those who get a full MDD diagnosis. There's this other group about 5% to 10% of kids and teens who experience what we call subsal.

Subs syndromeal. So they're not quite meeting the full criteria for MDD, but they're still struggling.

Yeah, exactly. They're experiencing some symptoms, maybe not enough for a full diagnosis, but they're having a tough time, you know, socially, academically, all that.

So it's still a big deal.

Oh, absolutely. And they're more more likely to have a family history of depression, a higher risk of attempting suicide, and they're more likely to eventually develop full-blown MDD. It's like a warning sign, you know.

Got it. So, for those who do meet the criteria for a full MDD diagnosis, what exactly are clinicians looking for? Like, what are those core symptoms based on the DSM5?

Okay, so the DSM5 lays out specific criteria for an MD diagnosis. Someone needs at least five of these symptoms during the same twoe period. At a really, really important point, one of those symptoms has to be either a depressed mood or a major loss of interest or pleasure in most activities.

Makes sense.

Now, the tricky thing with kids and teens is that depressed mood doesn't always look like, you know, classic sadness. It can actually show up as well, irritability.

Oh, interesting. So, a kid who's suddenly more irritable than usual, that could be a red flag.

Definitely. And along with that persistent sad or irritable mood and lack of interest, other symptoms we look for are well, significant changes in weight or appetite.

Yeah. For kids who are still growing, it might be a failure to gain weight as expected.

Got it. What else?

Sleep disturbances. We're talking about insomnia, trouble falling asleep or staying asleep, or the opposite, sleeping too much like hyperomnia. And that's happening almost every day. There might also be something called psychoot agitation, meaning they're restless, fidgety, can't sit still, or psychoot retardation, which is the opposite. They're moving and talking much slower than usual. These are things other people would notice.

So, it's not just what they're feeling. internally. It's also about changes in their behavior that are visible.

Exactly. Exactly. And then there's fatigue, just feeling wiped out all the time, lack of energy,

and feelings of worthlessness, guilt, like way more than is warranted.

Heavy stuff

it is. And then there's trouble concentrating, thinking clearly, making decisions, that kind of thing. And of course, recurrent thoughts of death. This can range from fleeting thoughts to, you know, very specific plans or even attempts.

And these symptoms They can't be explained by something else going on. Right.

Right. The DSM5 is clear about that. The symptoms can't be due to say substance use or another medical condition. And this is key. Those symptoms have to be causing real problems in the young person's life like their relationships, their schoolwork, just their ability to function dayto-day. It's about the impact, not just the symptoms themselves.

So once a clinician has identified these signs and symptoms, what happens next? How do they assess the situation and figure out about what needs to be done.

Well, a comprehensive assessment is crucial. It's not enough to just check off the symptoms. You need to understand the whole picture, right? You need to assess the severity of the depression. Is there any suicidal ideation or thoughts of harming others? Are there any signs of psychosis? Is substance use a factor? How agitated are they?

So many factors to consider.

Yeah. And you also need to look at things like how likely are they to actually follow through with treatment? Do their parents have any mental health conditions? And what's the family environment like?

It's It's really about understanding the context.

Exactly. This helps decide the intensity and the setting for care. Do they need outpatient therapy and medication or is it more serious requiring inpatient hospitalization? We're also seeing these collaborative care models emerging where mental health professionals work directly with primary care physicians. It's like having a mental health specialist right there in the family doctor's office.

Oh, I see. So, it's more accessible, less stigma.

Exactly. Now, in terms of measuring success. Well, we're looking for what we call treatment response.

Treatment response. So, basically, is the treatment working?

Yeah. It usually means either the young person no longer meets the criteria for MDD or there's been a significant reduction in their symptoms, like a 50% or greater decrease.

Okay. So, a noticeable improvement,

right? But even with a 50% reduction, they might still have some lingering symptoms. So, some clinicians aim for a score of 28 or lower on the children's depression rating scale revised or CDRS along with improved functioning for at least two weeks, you know, sustained improvement.

And are there other tools they use to gauge progress?

Yeah, they might use standardized scales like the CDRS. There's also the clinical global impression scale, specifically the improvement subscale or CGI gives an overall rating of how much the person has improved.

So, it's about looking at both the specific symptoms and the overall impact on their life.

Right. Clinicians also need to assess other things throughout treatment.

Yeah, definitely. If someone is on medication, it's super important to check if they're actually taking it as prescribed, if they're having any side effects, and what they and their parents or guardians believe about the benefits and risks of the medication.

Yeah, those beliefs can really affect whether someone sticks with treatment.

Absolutely. And it's really, really important to assess for any history of suicidal thoughts, homicidal ideiation, or physical symptoms before starting any medication.

Okay, why is that?

Well, it helps to differentiate between what was already there, potential side effects, and if their mood actually gets worse or they develop new problems while they're on the medication.

That makes sense. So, it's about having that baseline to compare to.

Now, let's talk about those initial steps in managing depression. What happens right after that diagnosis and assessment?

Psycho education. That's the first step, and it's super important both for the young person and their family. It's about explaining in clear terms what might be causing the depression, what those specific symptoms are, what the usual course of the illness looks like, and what the treatment options are. We talk about the risks and benefits of each approach.

So, knowledge is power.

Absolutely. And involving parents and sometimes even teachers as partners in treatment. It's crucial.

And research has shown that doing this psycho education can actually make people more likely to stick with their treatment and might even help to reduce symptoms on its own.

That's great.

Yeah. And if a parent has depression themselves, psycho education can be especially helpful because it helps them get better at solving problems related to their illness and dealing with any behavioral or attitude challenges that their kids might have. Giving them things to read and pointing them to good online resources can really help reinforce what you talk about, too.

That sounds very helpful.

Now, let's delve into those treatment approaches. What are the main options?

Well, the most common initial approach, especially for kids and teens, is actually psychotherapy on its own.

Really? Even more so than medication.

Yeah. Yeah.

Yeah.

And there's a lot of different types of therapy. But cognitive behavioral therapy or CBT and interpersonal therapy or IP have the most research backing them up, especially for adolescence.

Okay. CBT and IP, I think most people have heard of those, but maybe not everyone understands what they actually involve. Can you give us a quick rundown?

Sure. So, CBT is all about identifying and challenging those negative thought patterns and behaviors that are feeding the depression.

So, it's about recognizing those unhelpful thoughts and learning to reframe them.

Exactly. And then there's IP which focuses on relationships and social skills. The idea is that improving those areas can really impact someone's mood.

Interesting. So one is more about thoughts and the other is more about relationships.

Yeah, you could say that. And it's not always clear-cut which one is better. One study actually found IP to be more effective than CBT, but then another study by the same researchers found the opposite.

Wow. So it really depends on the individual.

Yeah, it does.

And one of the things that our sources really emphasize is that family dynamics are really important, too. too.

Yeah, that makes sense.

Attachment based family therapy has been shown to be more effective than just general supportive clinical management.

That's good to know. And it seems like IP has a particular focus, right?

Yeah, IP is really effective for adolescents with moderate to severe depression and for older teens. One of its main focuses is on addressing problems between parents and children, which is often a big factor in the depression.

What's great about IP is that it seems to be easier to adapt to different settings like school-based clinics.

That's Good news. Making therapy more accessible is so important. Now, let's shift gears and talk about medication. Specifically, what about pharmarmacological treatment using medication to address depression?

All right. So, medications, particularly a class called selective serotonin reuptake inhibitors or SSRIs, have been shown to improve both the symptoms of depression and overall functioning in adolescence and children with MDD. And there are actually two specific SSRIs that are FDA approved for use in young people.

So, they gone through the rigorous testing and approval process specifically for this age group.

Right? So fluoxitine which you might know as Prozac that's approved for children eight and older.

Okay.

And then there's Prem or Lexapro.

Here he means esatalopram or lexapro.

It's approved for adolescence ages 12 to 17.

So two options specifically for younger people. That's good to know. What does the research tell us about how effective they are?

Well studies have shown that flockitine even when used by itself can lead a real improvement in depressive symptoms in adolescence with MDD. And when it's combined with CBT, it might even help prevent future episodes of depression.

Interesting. So, medication plus therapy, we'll get to that in a bit. What about esatelopram?

Also been shown to improve both the core symptoms of depression and overall functioning in adolescence with MDD.

It's encouraging to know there are these options and they've been studied specifically in younger people, but I think a lot of people understandably have concerns about the potential risks of SSRIs, especially for kids and teens. What does the research say about that?

Yeah, that's a really important question and it's something we always need to consider carefully. The research does indicate that there's a potential for increased risk of serious side effects in young people taking SSRIs and they're also more likely to have withdrawal symptoms if they stop taking the medication suddenly.

So, careful monitoring and gradual tapering are essential.

Absolutely. And there's also been some concern about peroxitine, another SSRI, potentially being linked to a higher risk of suicidal thoughts or behaviors in adolescence with MDD compared to other SSRIs.

That's definitely something to be aware of.

And looking at the data as a whole, there does seem to be a slightly higher risk of suicidal thoughts and behaviors, although not always statistically significant across all SSRIs in this age group.

The FDA has issued warnings about this, so it's not something to take lightly. This is why it's absolutely vital to have close monitoring by a doctor when a young person is on any SSRI.

Absolutely. Benefits and risks need to be weighed carefully and regular check-ins with the doctor are essential. Now, let's talk about that combined approach you mentioned earlier. What about using both medication and psychotherapy together? What's the evidence there?

Well, there's really compelling evidence that combining fluoxitine with CBT can lead to greater improvement in depressive symptoms in adolescence with MDD. And studies have also shown that CBT plus medication could be associated with lower rates of relapse both in adolescence and children compared to using either treatment alone. There's this landmark study called the treatment for adolescence with depression study or TADS. TADS found that combining fluoxitine and CBT led to much bigger improvements in clinician rated depression, more kids achieving remission and better overall functioning compared to CBT alone, fluoxitine alone, or even a placebo.

So, the combination was clearly the most effective.

Yeah. And not only that, they also found that the combined treatment led to a faster response, meaning symptoms started improving sooner. That's huge. Especially when you talk about something as serious as depression,

right? Combining medication and therapy isn't just adding one thing on top of another. It's like they work together to create a much stronger effect.

Oh, okay. So, what happens if a young person doesn't respond to the initial treatment? Like what if they've tried therapy or medication alone and it's just not working?

That's when we start thinking about what we call treatment resistant depression. There are some strategies we can try. It's important to remember though that these haven't been studied as extensively in young people. as those first line treatments.

Got it. So, what are some of those strategies?

Well, we might try optimizing the medication, making sure they're on the right dose and have been on it long enough to see if it works. We might add CBT or IP if they haven't already tried that.

Makes sense.

We could also switch to a different anti-depressant or even add another medication to boost the effects of the first one.

Some examples of these add-on medications are bropen, lithium T3, or thyroxine T4. And in some cases, is a second generation antiscychotic medication.

So there are a lot of different options to try and I guess the decision about which one to use really depends on the individual person, right?

Yeah, exactly. Optimization and augmentation where you're basically trying to make the current treatment work better are usually considered if there's been some response even if it's not a complete remission. So a partial response. Okay. But switching meds is usually what you do if there's been little to no improvement or if the side effects are too much for them to handle.

Makes sense.

But it's important to say that even though These are common things that clinicians do. There haven't been a ton of studies looking specifically at how well and how safe these strategies are in kids and teens with MDD. So, it's about being flexible and adjusting the treatment plan based on how the person is responding.

Exactly.

Okay. And what about after someone starts feeling better like their depression is in remission? What happens then?

To prevent relapse, we usually recommend that they continue treatment, whether that's with SSRI, psychotherapy, or both. for at least 6 to 12 months after they've recovered from that initial episode.

So even though they're feeling better, it's important to keep those supports in place.

Yeah. And if someone has had a really severe episode or if their depression keeps coming back, they might need to stay on maintenance treatment for a year or even longer. Finally, our sources touched on some things that might affect how well a particular treatment works for someone. They call these moderators of treatment effects. And what did they find out about this?

Yeah, a few things. seem to be important. For example, in one study, having a lower family income, more severe depression symptoms at the beginning of treatment, and having ADHD all seem to make CBT less effective compared to fluoxitine.

Interesting.

Other things like having a history of trauma, having multiple mental health conditions at the same time, and a higher level of hopelessness reported by the young person might also affect treatment outcomes.

But the researchers who did this review really emphasize that we need more research to understand how all these different characteristics of the person might affect how well different treatments work.

That makes sense.

Yeah. And if we understand that better, it can help us to personalize treatments more. Giving the right treatment to the right person based on their unique situation. As we wrap up, are there any other key takeaways from the research that we should keep in mind?

Yeah, I think there are a few important things to highlight. First off, we have a lot more research on treating depression in adolescence than we do for younger children.

So, work to be done there.

Definitely. And the research we do have, well, it could be pretty varied. You know, different study designs, different types of therapy or medication, different groups of kids being studied. It makes it hard to compare the results sometimes.

That makes sense.

And we also have to remember the difference between statistical significance and clinical significance. Just because a study shows a statistically significant improvement, it doesn't always mean that it's a real meaningful change for that young person's life. Like Can they go back to school, hang out with friends, do the things they enjoy?

Right. It's about actual practical improvement.

Exactly. And to make things even more complicated, a lot of those psychotherapy studies, they don't always report on potential harms or side effects in the same way that medication trials do.

That's a good point. It's important to have a full picture.

And finally, we just need more research, more studies on how to help younger kids, on depression subtypes other than MDD, on the long-term effects of different treatments, on comparing different therapies head-to-head. always more to learn.

Always. We also need to figure out what constitutes a clinically meaningful change, like how much improvement is enough for a young person to feel better and function well. And we need more research on how to tailor treatments, like what works best for which kid based on their individual situation.

Those are all crucial points. It highlights how much we're still learning and evolving in this field. Okay. Last, but definitely not least, how should treatment decisions be made for a young person? struggling with depression.

It always needs to be a shared decision. The young person, their family, and the clinician all working together. It's about combining the best available evidence with what the young person wants, what their family feels comfortable with, and what fits their unique situation.

I love that it's not a one-sizefits-all approach.

Absolutely not.

So, to wrap up this incredibly informative deep dive, let's do a quick recap. We've covered how common depression is, the key criteria for diagnosis, and why a comprehensive assessment is so important. We've talked about the main treatment approaches psychotherapy like CBT and IP and medication especially those FDA approved SSRIs fluoxitine for kids eight and up and aalopram for teens 12 to 17

right right

we've also highlighted that combining medication therapy can be super effective especially for more severe cases and for preventing relapse but it's crucial to remember those potential risks associated with SSRIs and the importance of careful monitoring

absolutely and one last thing it's crucial to remember that this is complex. Every young person is different and their treatment needs to be tailored to their individual circumstances.

Couldn't agree more. All right, as we close, I want to leave you with something to think about. Imagine the possibilities if we could identify depression early on and provide integrated mental health support in places like schools and primary care settings. What could that mean for young people who are struggling or at risk? What systemic changes would really move the needle and ensure that everyone has access to the care they need when They need it.

Yeah. What could we achieve if mental health was truly woven into the fabric of our communities?

Exactly. Thanks for joining us for this deep dive.

Yeah. Thanks everyone.