eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Depression: Follow-up

Author: Tami D Benton, MD, Director of Clinical Services, Program Director, Department of Psychiatry, Children's Hospital of Philadelphia; Assistant Professor, University of Pennsylvania
Contributor Information and Disclosures

Updated: Jul 15, 2009

Follow-up

Further Inpatient Care

  • Major depression with psychotic features, such as hallucinations, places an individual at increased risk of harm to themselves or others and is an indication for hospitalization.
  • The real possibility and potential for suicide with concrete planning by the patient warrants hospitalization.
  • Suicide recidivism is another potential cause for hospitalization.
  • The failure of the family support system when confronting depression with suicidal ideation again may be a strong indicator for temporary hospitalization in an attempt to stabilize and improve family functioning.
  • Risk factors for completed suicide include the presence of a major mood disorder, occurrence of command auditory hallucinations, use of substances, and evidence of plans to prevent discovery, as well as patient perception of failure of the issues that precipitated suicidal thinking to change. This lack of action tends to escalate the patients' sense of hopelessness.

Further Outpatient Care

Complications

  • Because of individual variation in the pharmacokinetics of TCAs, monitoring plasma concentration is helpful to determining optimal dosage. A plasma level of 150-250 mg/mL is considered the range of therapeutic effectiveness, although an upper level in children has not been established.
  • Perform ECG before starting TCA therapy.
  • Be alert to changes in the patient that might signify a switch from a depressive state to a manic state. Childhood-onset depression is commonly a precursor of bipolar disorder.
  • TCAs in large doses can be lethal and should be avoided in youths who are at risk for suicidal behaviors.

Prognosis

  • According to the American Academy of Child and Adolescent Psychiatry practice parameters for depressive disorders in childhood and adolescence, a history of a previous depressive episode, subsyndromal symptoms of depression, dysthymia, and anxiety disorders increase the risk for future depression.33 Familial, social, and environmental factors appear to play significant roles in the course of depressive illness in children and youths. Good evidence indicates that depression can be recurrently noted in families from generation to generation. Thus, a thorough family history is quite important.
  • In 1999, in a 9-year study of an epidemiologic sample of 776 adolescents, Pine and associates found that symptoms of major depression in adolescence strongly predicted adult episodes of major depression.34

Patient Education

  • Educating parents about children's emotional problems is very important. Education is known to result in better compliance with treatment and to improve parents' understanding toward their children. Patients should be educated in a manner congruent with individual development, level of impairment, and clinician judgment.
  • The clinician should instruct parents and others in the homes of depressed youths to remove firearms from their homes to decrease the risk of suicide. Household medications also should not be accessible to depressed youths.
  • For excellent patient education resources, visit eMedicine's Depression Center, Substance Abuse Center, and Antidepressants Center. Also, see eMedicine's patient education articles Depression, Substance Abuse, and Understanding Antidepressant Medications.

Miscellaneous

Medicolegal Pitfalls

  • Risk assessment of patients who are depressed should be ongoing.
  • The clinician must have a safety plan in place for patients with suicidal ideation that includes no access to medications or other means of self-harm plus constant supervision.
  • Consider hospitalization for patients for whom an effective safety plan and supervision is not feasible and for those patients and families unable or unlikely to comply with treatment recommendations.
  • Do not use TCAs as a first-line treatment for patients with suicidal ideation.
  • Documentation should support clinical decision-making.
 


More on Depression

Overview: Depression
Differential Diagnoses & Workup: Depression
Treatment & Medication: Depression
Follow-up: Depression
References
[ CLOSE WINDOW ]

References

  1. Kashani JH, Sherman DD. Childhood depression: Epidemiology, etiological models, and treatment implications. Integr Psychiatry. 1988;6:1-8.

  2. Garrison CZ, Waller JL, Cuffe SP, et al. Incidence of major depressive disorder and dysthymia in young adolescents. J Am Acad Child Adolesc Psychiatry. Apr 1997;36(4):458-65. [Medline].

  3. Murphy JM, Laird NM, Monson RR, et al. Incidence of depression in the Stirling County Study: historical and comparative perspectives. Psychol Med. May 2000;30(3):505-14. [Medline].

  4. Copeland JR, Beekman AT, Dewey ME, et al. Depression in Europe. Geographical distribution among older people. Br J Psychiatry. Apr 1999;174:312-21. [Medline].

  5. Jablensky A, Sartorius N, Gulbinat W, Ernberg G. Characteristics of depressive patients contacting psychiatric services in four cultures. A report from the who collaborative study on the assessment of depressive disorders. Acta Psychiatr Scand. Apr 1981;63(4):367-83. [Medline].

  6. Siegel JM, Aneshensel CS, Taub B. Adolescent depressed mood in a multiethnic sample. J Youth Adolesc. 1998;27.

  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM- IV). 4th ed. Washington, DC: American Psychiatric Association; 1994.

  8. Hankin BL, Abramson LY, Moffitt TE, et al. Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol. Feb 1998;107(1):128-40. [Medline].

  9. Steingard RJ, Renshaw PF, Yurgelun-Todd D, et al. Structural abnormalities in brain magnetic resonance images of depressed children. J Am Acad Child Adolesc Psychiatry. Mar 1996;35(3):307-11. [Medline].

  10. Tutus A, Kibar M, Sofuoglu S, et al. A technetium-99m hexamethylpropylene amine oxime brain single-photon emission tomography study in adolescent patients with major depressive disorder. Eur J Nucl Med. Jun 1998;25(6):601-6. [Medline].

  11. De Bellis MD, Dahl RE, Perel JM, et al. Nocturnal ACTH, cortisol, growth hormone, and prolactin secretion in prepubertal depression. J Am Acad Child Adolesc Psychiatry. Sep 1996;35(9):1130-8. [Medline].

  12. Nobile M, Begni B, Giorda R, et al. Effects of serotonin transporter promoter genotype on platelet serotonin transporter functionality in depressed children and adolescents. J Am Acad Child Adolesc Psychiatry. Nov 1999;38(11):1396-402. [Medline].

  13. Birmaher B, Kaufman J, Brent DA, et al. Neuroendocrine response to 5-hydroxy-L-tryptophan in prepubertal children at high risk of major depressive disorder. Arch Gen Psychiatry. Dec 1997;54(12):1113-9. [Medline].

  14. Akiskal HS, Weller ES. Mood disorders and suicide in children and adolescents. In: Kaplan HI, Saddock BJ, eds. Comprehensive Textbook of Psychiatry. Vol 2. 5th ed. Lippincott Williams & Wilkins; 1989.

  15. Weissman MM, Leckman JF, Merikangas KR, et al. Depression and anxiety disorders in parents and children. Results from the Yale family study. Arch Gen Psychiatry. Sep 1984;41(9):845-52. [Medline].

  16. Hammen C, Burge D, Adrian C. Timing of mother and child depression in a longitudinal study of children at risk. J Consult Clin Psychol. Apr 1991;59(2):341-5. [Medline].

  17. Weller EB, Weller RA, Fristad MA, et al. The dexamethasone suppression test in prepubertal depressed children. J Clin Psychiatry. Dec 1985;46(12):511-3. [Medline].

  18. Mufson L, Fairbanks J. Interpersonal psychotherapy for depressed adolescents: a one-year naturalistic follow-up study. J Am Acad Child Adolesc Psychiatry. Sep 1996;35(9):1145-55. [Medline].

  19. Kroll L, Harrington R, Jayson D, et al. Pilot study of continuation cognitive-behavioral therapy for major depression in adolescent psychiatric patients. J Am Acad Child Adolesc Psychiatry. Sep 1996;35(9):1156-61. [Medline].

  20. Brent DA, Kolko DJ, Birmaher B, et al. Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. J Am Acad Child Adolesc Psychiatry. Sep 1998;37(9):906-14. [Medline].

  21. [Best Evidence] Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, Gladstone TR, et al. Prevention of depression in at-risk adolescents: a randomized controlled trial. JAMA. Jun 3 2009;301(21):2215-24. [Medline].

  22. Leonard HL, March J, Rickler KC, Allen AJ. Pharmacology of the selective serotonin reuptake inhibitors in children and adolescents. J Am Acad Child Adolesc Psychiatry. Jun 1997;36(6):725-36. [Medline].

  23. Rey-Sanchez F, Gutierrez-Casares JR. Paroxetine in children with major depressive disorder: an open trial. J Am Acad Child Adolesc Psychiatry. Oct 1997;36(10):1443-7. [Medline].

  24. Emslie GJ, Rush AJ, Weinberg WA, et al. A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry. Nov 1997;54(11):1031-7. [Medline].

  25. King RA, Segman RH, Anderson GM. Serotonin and suicidality: the impact of acute fluoxetine administration. I: Serotonin and suicide. Isr J Psychiatry Relat Sci. 1994;31(4):271-9. [Medline].

  26. Teicher MH, Glod CA, Cole JO. Antidepressant drugs and the emergence of suicidal tendencies. Drug Saf. Mar 1993;8(3):186-212. [Medline].

  27. Carlsten A, Waern M, Ekedahl A, Ranstam J. Antidepressant medication and suicide in Sweden. Pharmacoepidemiol Drug Saf. Oct-Nov 2001;10(6):525-30. [Medline].

  28. Hall WD, Mant A, Mitchell PB, et al. Association between antidepressant prescribing and suicide in Australia, 1991-2000: trend analysis. BMJ. May 10 2003;326(7397):1008. [Medline]. [Full Text].

  29. Olfson M, Marcus SC, Druss B, Pincus HA. National trends in the use of outpatient psychotherapy. Am J Psychiatry. Nov 2002;159(11):1914-20. [Medline]. [Full Text].

  30. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. Aug 18 2004;292(7):807-20. [Medline].

  31. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

  32. Department of Health and Human Services, US Food and Drug Administration, Center for Drug Evaluation and Research. Antidepressant Use in Children, Adolescents, and Adults: Labeling Template. www.fda.gov/cder/drug/antidepressants/PI_template.pdf. Available at http://www.fda.gov/cder/drug/antidepressants/PI_template.pdf.. Accessed February 28,2005.

  33. AACAP. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. AACAP. J Am Acad Child Adolesc Psychiatry. Oct 1998;37(10 Suppl):63S-83S. [Medline].

  34. Pine DS, Cohen E, Cohen P, Brook J. Adolescent depressive symptoms as predictors of adult depression: moodiness or mood disorder?. Am J Psychiatry. Jan 1999;156(1):133-5. [Medline]. [Full Text].

  35. Ambrosini PJ, Wagner KD, Biederman J, et al. Multicenter open-label sertraline study in adolescent outpatients with major depression. J Am Acad Child Adolesc Psychiatry. May 1999;38(5):566-72. [Medline].

  36. Birmaher B, Brent DA, Kolko D, et al. Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. Arch Gen Psychiatry. Jan 2000;57(1):29-36. [Medline].

  37. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry. Nov 1996;35(11):1427-39. [Medline].

  38. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part II. J Am Acad Child Adolesc Psychiatry. Dec 1996;35(12):1575-83. [Medline].

  39. Clarke GN, Rohde P, Lewinsohn PM, et al. Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions. J Am Acad Child Adolesc Psychiatry. Mar 1999;38(3):272-9. [Medline].

  40. Daly JM, Wilens T. The use of tricyclic antidepressants in children and adolescents. Pediatr Clin North Am. Oct 1998;45(5):1123-35. [Medline].

  41. Drevets WC, Price JL, Simpson JR, et al. Subgenual prefrontal cortex abnormalities in mood disorders. Nature. Apr 24 1997;386(6627):824-7. [Medline].

  42. Geller B, Reising D, Leonard HL, et al. Critical review of tricyclic antidepressant use in children and adolescents. J Am Acad Child Adolesc Psychiatry. May 1999;38(5):513-6. [Medline].

  43. Hamilton J, Gillham J. The K-SADS and diagnosis of major depressive disorder. J Am Acad Child Adolesc Psychiatry. Sep 1999;38(9):1065-9. [Medline].

  44. Hazell P, O'Connell D, Heathcote D, Robertson J, Henry D. Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis. BMJ. Apr 8 1995;310(6984):897-901. [Medline].

  45. Hendren RL, De Backer I, Pandina GJ. Review of neuroimaging studies of child and adolescent psychiatric disorders from the past 10 years. J Am Acad Child Adolesc Psychiatry. Jul 2000;39(7):815-28. [Medline].

  46. Hovey JD, King CA. Acculturative stress, depression, and suicidal ideation among immigrant and second-generation Latino adolescents. J Am Acad Child Adolesc Psychiatry. Sep 1996;35(9):1183-92. [Medline].

  47. Kovacs M, Gatsonis C. Secular trends in age at onset of major depressive disorder in a clinical sample of children. J Psychiatr Res. May-Jun 1994;28(3):319-29. [Medline].

  48. Kurian BT, Ray WA, Arbogast PG, et al. Effect of regulatory warnings on antidepressant prescribing for children and adolescents. Arch Pediatr Adolesc Med. Jul 2007;161(7):690-6. [Medline].

  49. Lewinsohn PM, Clarke GN, Seeley JR, Rhode P. Major depression in community adolescents: age at onset, episode duration, and time to recurrence. J Am Acad Child Adolesc Psychiatry. Jul-Aug 1994;33(6):809-18. [Medline].

  50. Lewinsohn PM, Hops H, Roberts RE, et al. Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abnorm Psychol. Feb 1993;102(1):133-44. [Medline].

  51. Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. J Am Acad Child Adolesc Psychiatry. Jan 1999;38(1):56-63. [Medline].

  52. Newman TB. A black-box warning for antidepressants in children?. N Engl J Med. Oct 14 2004;351(16):1595-8. [Medline].

  53. Schulterbrandt JG, Raskin A. Depression in Childhood: Diagnosis, Treatment and Conceptual Models. New York, NY: Raven Press; 1977.

  54. Strober M, DeAntonio M, Schmidt-Lackner S, et al. The pharmacotherapy of depressive illness in adolescents: an open-label comparison of fluoxetine with imipramine-treated historical controls. J Clin Psychiatry. Mar 1999;60(3):164-9. [Medline].

  55. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 7th ed. Hudson, Ohio: Lexi-Comp, Inc; 2000.

  56. Wagner KD, Ambrosini P, Rynn M, et al. Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials. JAMA. Aug 27 2003;290(8):1033-41. [Medline].

  57. Weller EB, Weller RA. Clinical aspects of childhood depression. Pediatr Ann. Dec 1986;15(12):843-7. [Medline].

  58. Wickramaratne PJ, Greenwald S, Weissman MM. Psychiatric disorders in the relatives of probands with prepubertal- onset or adolescent-onset major depression. J Am Acad Child Adolesc Psychiatry. Nov 2000;39(11):1396-405. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

major depressive disorder, MDD, manic-depressive disorder, bipolar disorder, suicide, suicidal ideation, childhood depression, serotonin, auditory hallucinations, depressed mood, sleep disturbance, catalepsy, seasonal mood disorder, seasonal affective disorder, attention deficit hyperactivity disorder, ADHD, anxiety, posttraumatic stress disorder

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Tami D Benton, MD, Director of Clinical Services, Program Director, Department of Psychiatry, Children's Hospital of Philadelphia; Assistant Professor, University of Pennsylvania
Tami D Benton, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.