The clinical picture of depression in preschool children

OBJECTIVE: To investigate the clinical characteristics of depression in preschool children. METHOD: One hundred seventy-four subjects between the ages of 3.0 and 5.6 years were ascertained from community and clinical sites for a comprehensive assessment that included an age-appropriate psychiatric interview for parents. Modifications were made to the assessment of major depressive disorder (MDD) criteria so that age-appropriate manifestations of symptom states could be captured. Typical and "masked" symptoms of depression were investigated in three groups: depressed (who met all MDD criteria except duration criterion), those with nonaffective psychiatric disorders (who met criteria for attention-deficit/hyperactivity disorder and/or oppositional defiant disorder), and those who did not meet criteria for any psychiatric disorder. RESULTS: Depressed preschool children displayed "typical" symptoms and vegetative signs of depression more frequently than other nonaffective or "masked" symptoms. Anhedonia appeared to be a specific symptom and sadness/irritability appeared to be a sensitive symptom of preschool MDD. CONCLUSIONS: Clinicians should be alert to age-appropriate manifestations of typical MDD symptoms and vegetative signs when assessing preschool children for depression. "Masked" symptoms of depression occur in preschool children but do not predominate the clinical picture. Future studies specifically designed to investigate the specificity and sensitivity of the symptoms of preschool depression are now warranted.     

Pharmacotherapy for major depression in children and adolescents

Major depression is a serious illness in children which adversely effects their social, academic, and emotional development. It is essential to identify safe and effective medication for the treatment of this disorder in youths. Only some selective serotonin reuptake inhibitors (citalopram, fluoxetine, sertraline) have demonstrated superiority to placebo on primary outcome measures in acute controlled treatment trials. This article will review acute efficacy studies as well as long-term studies of antidepressants for the treatment of childhood depression. Treatment recommendations are discussed and the issue of suicidality and antidepressants are addressed.     

A review of pharmacotherapy of major depression in children and adolescents

OBJECTIVE: The review examined the historical progression and current status of pharmacotherapy of child and adolescent major affective disorder. METHODS: A MEDLINE search was used to identify double-blind, placebo-controlled studies of child and adolescent major depression. Only studies that used reliable diagnostic and recovery parameters were included. RESULTS: Few well-designed studies have compared placebo and tricyclic antidepressants in the treatment of major depressive disorder in children and adolescents. However, results consistently suggest that tricyclic antidepressants are not efficacious. Early results of double-blind placebo-controlled trials with fluoxetine and paroxetine have shown a significant drug effect. However, the results are inconsistent, which could reflect the ways that response to medication is defined, the ways that rating scales measure recovery, and uncertainties of dosing strategies with second-generation antidepressants. Hypothesized reasons for the unique response pattern in youths include the changing hormonal status of children, the differential maturation of the noradrenergic versus serotonergic neurotransmitter systems, and the possibility that a large proportion of depressed youths are in the early stages of bipolar disorder, which is not effectively treated by these medications. CONCLUSIONS: Tricyclic antidepressants are not superior to placebo for the treatment of child and adolescent major depressive disorder. Although two of three trials of second-generation antidepressants in this age group have had negative results, data suggest that these drugs may be more promising. It is too early in our investigation to know whether these agents will be effective in treating major depressive disorder in children and adolescents.     

Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents

OBJECTIVE: The authors compared fluoxetine and placebo in continuation treatment to prevent relapse of major depressive disorder in children and adolescents. METHOD: After a detailed evaluation, children and adolescents 7-18 years of age with major depressive disorder were treated openly with fluoxetine. Those who had an adequate response after 12 weeks, as indicated by a Clinical Global Impression improvement score of 1 or 2 and a decrease of at least 50% in Children's Depression Rating Scale-Revised score, were randomly assigned to receive fluoxetine or placebo for an additional 6 months. The primary outcome measures were relapse and time to relapse. Relapse was defined as either a score of 40 or higher on the Children's Depression Rating Scale with a history of 2 weeks of clinical deterioration, or clinical deterioration as judged by the clinician. Additional analyses were conducted with relapse defined only as a score of 40 or higher on the Children's Depression Rating Scale. RESULTS: Of 168 participants enrolled in acute fluoxetine treatment, 102 were randomly assigned to continuation treatment with fluoxetine (N=50) or placebo (N=52). Of these, 21 participants (42.0%) in the fluoxetine group relapsed, compared with 36 (69.2%) in the placebo group, a significant difference. Similarly, under the stricter definition of relapse, fewer participants in the fluoxetine group relapsed (N=11; 22.0%) than in the placebo group (N=25; 48.1%). Time to relapse was significantly shorter in the placebo group. CONCLUSIONS: Continuation treatment with fluoxetine was superior to placebo in preventing relapse and in increasing time to relapse in children and adolescents with major depression.     

Immunity in adolescents with major depression

OBJECTIVE: The association between major depression (MD) and altered immunity appears to be age-related, with differing immune changes found in prepubertal children, young adults, and older adults. There is limited information concerning immunity in adolescents with MD. METHOD: Thirty-six otherwise healthy medication-free adolescents (aged 14-20; 23 female) from a community sample, meeting Diagnostic Interview Schedule for Children DSM-III-R criteria for unipolar MD, were compared with 36 nondepressed adolescents matched by gender, age, and racial background. A battery of quantitative and functional immune measures was obtained. RESULTS: MD adolescents had increased (p < .05) circulating lymphocytes and lymphocyte subsets; however, altered distribution of lymphocyte subsets was found only for activated T (HLA-DR+) cells (p < .004) and, possibly, natural killer (NK) (CD56+) cells (p < .06), each showing lower percentages in the MD adolescents. Concanavalin A (but not phytohemagglutinin or pokeweed mitogen) mitogen response was lower in the MD adolescents (p < .02). NK cell activity was elevated at higher effector-target ratios (p < .001), an effect not associated with the number of circulating CD56+ (NK) cells. CONCLUSIONS: Depressed adolescents showed changes in immune measures that have been found to be altered in other MD groups, although the pattern of effects differs.     

Atypical depression in children and adolescents

Major depressive disorder (MDD) with atypical features has been described in adults. Furthermore, several studies have suggested that tricyclic antidepressants were less effective for MDD with atypical features than for MDD without atypical features. Thus, it may be important to determine whether atypical features are present in MDD. To date, only one study has examined the diagnosis of depression with atypical features in children and adolescents by using the DSM-IV criteria. Current knowledge suggests the DSM-IV criteria for depression with atypical features in children and adolescents may need to be reconsidered, as biological, hormonal, developmental, and psychological factors in this age group may be different from those of adults with atypical depression.     

Refractory depression in children and adolescents

Refractory or treatments resistant depression in child and adolescent populations is a difficult construct to operationalize currently. To date, only one of the small number of completed double-blind placebo-controlled treatment investigations have not demonstrated a significant effect of antidepressants in comparison to placebo. However, it has been established that child and adolescent MDD is a serious disorder that appears to have clinical continuity with adult affective disorders and is generally of long duration with high rates of recurrence and eventual progression to mania, substance abuse, or other serious psychopathology. In addition, families of children with affective disorders evidence substantial genetic loading with high rates of affective disorders contributing both genetic vulnerability and potential environmental risk as well. There have been no empirically identified treatments that alter the long-term course of the illness. Thus treatment resistance is a significant issue for this population. This review will focus on controlled treatment trials and will examine the potential relevance of psychosocial impairment, genetic-familial risk, and neuromorphometric brain differences to treatment resistance in children and adolescents with major depression. Depression and Anxiety 5:212–223, 1997. © 1997 Wiley-Liss, Inc.     

Assessment of depression in children and adolescents

Depression assessment instruments are valuable tools in the treatment of children and adolescents. Available instruments include diagnostic interviews, self-administered rating scales, and observer-rated scales. To select an appropriate instrument, the user must define the goal of the assessment and then identify instruments with the properties that match this goal. This article discusses how to choose an assessment instrument and gives an overview of currently available depression assessment instruments. Important considerations include how and by whom an instrument is administered, what kind of data are obtained by the instrument, and the validity and reliability of the instrument. Standardized instruments can greatly improve the assessment process, but the user must not overinterpret or misinterpret the results.     

Neurobiology of depression in children and adolescents

This article reviews classical and updated studies of the neurobiology of depressive disorders in children and adolescents. Most studies of childhood and adolescent depression and suicide have followed up the observations and methods used in studies in adults. These studies include neuroendocrine studies, which particularly look at the hypothalamic-pituitary-adrenal axis, the serotonergic system, peripheral blood and cerebrospinal fluid biologic markers, genetics, gene-environment interactions and sleep studies, and neuroimaging and postmortem studies, although in these areas the number of studies is limited.     

Treatment of depression in children and adolescents

Depression occurs in children and adolescents, although it may appear differently in younger patients. Research suggests juvenile depression may respond to psychotherapy and to pharmacologic agents, and that antidepressants remain a valuable treatment for juveniles with depression. Diagnostic considerations in juveniles with mood symptoms are discussed. A brief overview is provided of the evidence supporting psychotherapy for juveniles with depression. Controlled antidepressant trials in juveniles with depression provide some support for the use of some selective serotonin reuptake inhibitors and little support for atypical antidepressants, tricyclic antidepressants, or monoamine oxidase inhibitors. Evidence from suicide rates over time, autopsy findings among juvenile suicides, and impacts of antidepressant prescribing trends are related to the current controversy over suicidality and antidepressant use in juvenile patients. Based on this evidence, practical guidelines for treatment of juvenile depression are provided.     

Polysomnographic findings in adolescents with major depression

Ten adolescents with major depression and 10 age-matched controls were studied with polysomnography for 3 consecutive nights. The sleep records were analyzed for variables pertaining to sleep continuity (total sleep time, sleep efficiency, sleep onset latency, number of awakenings, and number of stage shifts), sleep architecture (Stages 1, 2, 3, and 4), and rapid eye movement (REM) sleep (total) REM sleep time, number of REM periods, REM latency, and REM density). The experimental and control groups were compared on 14 variables with the t test for independent groups. The results indicated that none of the sleep variables differed significantly between the two groups. These results confirm earlier findings indicating that the abnormalities in REM latency and REM density that characterize adults with major depression are absent in adolescents suffering from major depression. Developmental and diagnostic variables are discussed as possible explanations for the sleep differences between adolescents and adults with depressive disorders.     

The relationship of anxiety to depression in children and adolescents

The relationship of anxiety to depression in children and adolescents has perplexed and preoccupied researchers and professionals in the field of child and adolescent psychiatry over the last two decades. This article illustrates this as it is demonstrated through epidemiologic, genetic, and biologic issues as well as environmental and developmental considerations and investigated procedures. The relevant literature is reviewed in depth, and the discussion on the inter-relatedness of the various factors, as they influence anxiety and depression, is brought forth.     

儿童青少年与老年抑郁症患者自杀危险因素比较

目的 比较精神科儿童青少年和老年抑郁症患者的自杀危险因素,认识两类人群自杀危险的特点,有针对性地预防自杀.方法 采用自制的自杀危险评估表对210例儿童青少年和老年抑郁症患者进行评估.结果 在健康状况、焦虑程度、药物副反应、自杀史、人际关系、性格特征方面儿童青少年和老年患者存在明显差异.结论 儿童青少年和老年抑郁症患者自杀意念具有不同的特点,需根据不同特点针对性地采取不同的预防措施.     

The clinical picture of bipolar II outpatient depression in private practice

Uncertainties exist about whether depressive episodes differ phenomenologically in unipolar and bipolar II patients. The aim of the present study was to better define the clinical picture and course of bipolar II depression. Three hundred and ninety-nine consecutive outpatients, presenting for treatment of unipolar and bipolar II depression, were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery-Asberg Depression Rating Scale and the Global Assessment of Functioning Scale. Bipolar II depression had significantly lower age at onset, more recurrences and more patients with DSM-IV atypical features. Gender, duration of illness, psychosis, chronicity, severity, axis I comorbidity, melancholic features, individual atypical symptoms and other symptoms of depression were not significantly different. The presence of DSM-IV atypical features predicted bipolar II diagnosis with 63% probability.     

The DST in children and adolescents with major depressive disorder

The authors analyzed dexamethasone suppression test (DST) results from 13 prospective studies on the use of the DST in children and adolescents with psychiatric disorders. Sensitivity of the DST was significantly higher among the children than among the adolescents with major depressive disorder (69.6% and 47.1%, respectively), and specificity was significantly lower (69.7% and 80.2%). Significantly more adolescents with major depressive disorder than with other psychiatric diagnoses, especially conduct disorder, were nonsuppressors. The authors discuss possible explanations for the high DST sensitivity among the children and point out the potential usefulness of the DST in differentiating major depressive disorder from conduct disorder.     

Medical treatment of depression in children and adolescents

Pharmacological treatment of depression in minors is contested after some published warnings about suicide related behaviour among youths treated with SSRI. This paper examines the last developments concerning antidepressant use in minors, prescrition patterns and evidence of antidepressants used in minors. Reviewing the guidelines and practise parameters, metaanalyses and the TADS-study a recommendation for an evidence based use in minors can only be given for Fluoxetine. Safety aspects should be taken into consideration during the treatment and patients should be kept in close contact to their therapists to observe suicidal related behaviour and adherence.