Pediatric Persistent Depressive Disorder (Dysthymia) 

Updated: Oct 14, 2016
Author: Jeffrey S Forrest, MD; Chief Editor: Caroly Pataki, MD 

Overview

Background

Persistent depressive disorder, or PDD, represents the DSM-5 consolidation of previously defined DSM-IV-TR diagnoses (persistent depressive disorder and chronic major depressive disorder).[1]  PDD may be diagnosed in pediatric patients, either children or adolescents, when a pervasive depressed or irritable mood is present for at least 1 year. Two additional symptoms of depression must also be present for most of the day at least half of the time during that year to make the diagnosis. Depressive symptoms typical in persisten depressive disorder include the following[1] (see Prognosis, Presentation, and Workup):

  • Diminished or increased appetite

  • Insomnia or hypersomnia

  • Low energy or fatigue

  • Poor self-esteem

  • Difficulties with concentration or decision making

  • Feelings of hopelessness

To qualify for a diagnosis of PDD, a child may have never had a manic or hypomanic episode. A child may not have had symptom-free intervals lasting longer than two months.

Patient education

Education about the long-term risks of dysthymic disorder and the role of behavioral and cognitive-behavioral interventions, as well as instruction in social and interpersonal skills, can be helpful adjuncts to treatment. (See Treatment.)

For patient education information, see the Depression Center, as well as Depression.

Etiology

Depressive disorders are etiologically heterogeneous. Genetic, biologic, psychological, and environmental factors contribute to depression. Much of the following discussion applies to many depressive disorders, including persistent depressive disorder. Persistent depressive disorder and depression likely arise from a complex relationship among elements such as genetic predisposition, disrupted attachments, internal psychological representations and attributions, dysfunctional social interactions, risk and protective factors, and melancholic endocrine changes.

Familial factors

Genetic factors are considered to account for approximately 50% of the variance in the transmission of depressive disorders. Children of parents who are depressed are 3 times more likely to experience a depressive episode than are children of parents who are not depressed; 20-45% of parents of depressed children have depressive disorders.

However, the specificity of these findings is clouded by the fact that psychopathology generally is more common in parents of depressed children and depressed parents generally produce children with other psychopathology as well.

Transmission of depression in families may also occur by means of nongenetic pathways; environmental stressors increase in families with depressed members. Temperament modulates the expression of genetic variance. Temperament is defined as a long-standing behavioral style, mostly inherited, evident early in life, stable during time, and observable in various settings. Some temperamental patterns are likely to make individual children more vulnerable to depression and other disorders.

Biologic factors

The biologic substrate for mood disorders is the basis of pharmacologic treatment. Several neurotransmitter systems have been hypothesized to be involved in the emergence of depressive disorders, including the noradrenergic, serotonergic, cholinergic, and dopaminergic systems.

The biogenic amines, norepinephrine and serotonin, regulate mood, sleep, appetite, and activity; they are implicated in persistent depressive disorder and are modified by the current antidepressant drugs.

Studies of adults with depression have shown blunted responses of cortisol secretion in response to serotonergic challenges. One study's results suggested that depressed children may also show a blunted cortisol secretion response when challenged with serotonergic agents.

In addition, studies in adults have shown that there are lower levels of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) of persons who attempt suicide and those who complete it. Studies have indicated that children with depressive disorders may have blunted growth hormone responses when challenged with adrenergic agents, such as clonidine (Catapres).

Among adults with depression, evidence of sleep abnormalities have been reported, including reduced slow wave (delta) sleep, diminished latency to rapid eye movement (REM) sleep, increased REM density, and increased awakening during the night. Sleep disturbance studies in children and adolescents experiencing depression widely vary. Some evidence suggests that children and adolescents with recurrent depression may have shorter REM latency during the period of depression, as well as during periods of remission.

Biologic measures cannot be used to rule in or out particular mood disorders. It is hypothesized that maturational differences in neurotransmitter systems account for psychobiologic differences observed in pediatric and adult depressive disorders.

Psychological factors

Three main theories have been studied in the etiology of depressive disorders. Psychoanalytic theory relates the origin of depression to loss of love objects. Behavioral theories focus on the concept of learned helplessness. Cognitive behavioral theories suggest that depressive disorders are related to negative appraisals of the self and of one's competence and abilities. All of the above models suggest that a person vulnerable to depression responds to adversity by withdrawal and inaction.

Environmental factors

Life events and family functioning are considered to be potential risk factors or protective factors in the development of dysthymia and other depressive disorders. Families with poor coping abilities, low levels of communication within the family, high levels of intrafamilial conflict, and inconsistent emotional response teach children maladaptive affective regulation. If traumatic life events occur, children reared in chaotic environments have increased vulnerability to depressive outcomes.

Studies have shown that negative life events are more likely to be associated with the onset of emotional disorders if maternal distress and a poor mother-child relationship are present. Alternatively, good parent-child and good familial relationships can mitigate the effects of traumatic life events. Recent studies support multiple-level models of resilience indicating effects of both biological and psychosocial factors.[2]

Epidemiology

Occurrence in the United States

Point prevalence rates of 0.6-1.7% in children and 1.6-8% in adolescents have been reported.

International occurrence

Rates in Europe generally correspond with US rates. Developing countries have a higher prevalence of minor psychiatric illnesses in general. A study of children and adolescents in an urban environment in Turkey concluded that persistent depressive disorder was the most common depressive disorder. Low maternal education, low socioeconomic status, dysfunctional interaction with the father, anxiety, and low self-esteem, which were all associated with depression, may be the target of interventions for prevention and treatment of depression.[3]

Race-related demographics

Limited data suggest that the prevalence of dysthymia among ethnic minority pediatric populations is similar to or lower than the prevalence in white pediatric populations in the United States.

Sex-related demographics

Major depressive disorder has a male-to-female prevalence ratio of 1:1 in prepubertal children and 1:2 in adolescents. In children, persistent depressive disorder appears to occur equally in both sexes. Authors have speculated as to why rates of depression go up in adolescence, especially in girls. Biologic, psychosocial, and cognitive factors probably contribute.

One hypothesis is that girls are more likely to deal with stressors in a ruminative and openly expressive way, in addition to entering puberty earlier than boys (with the concomitant psychosocial and biologic consequences). As adolescents, females are more likely to be exposed to sexual abuse, worry about their body image, and feel pressure to conform to restrictive social images than are males.

Age-related demographics

Studies of depression in the pediatric population show a rise in frequency with age. Rates and gender ratios approach adult levels with older adolescents, although these data are subject to interpretation based on changing diagnostic criteria for depression over time.

Years ago, depression was not diagnosed in childhood. According to the Freudian concept that depression is based on the individual's response to loss, children were thought to be incapable of depression because their psychosexual development was believed to be too immature to produce it.

In the 1960s, it was suggested that children suffer "masked depression"; that is, that typical depressive symptoms are expressed as equivalents such as hyperactivity, learning disabilities, and encopresis. However, scrutiny of clinical reports over the last 100 years had led to the conclusion that the same core symptoms of depression observed in adolescents and adults also occur in children.

Children are now widely believed to express depressive symptoms in a manner consistent with their developmental level, including their ability to articulate their feelings and reflect on their mood. Thus, the frequency of various depressive symptoms in children is developmentally linked; depressed prepubertal children may manifest more somatic complaints, self-esteem difficulties, and sad facial expression than do adolescents and adults.

The core depressive symptoms in affective disorders can be shown to be present in children as well as in adults if the assessment tool used is developmentally sensitive.

Prognosis

Children who experience persistent depressive disorder (PDD) have a mean episode length of 3–4 years (1-year duration is required for the diagnosis). The presence of a comorbid externalizing disorder appears to add almost 2.5 years to the episode length, which suggests that the comorbidity should be addressed first.

The spontaneous remission rate for all patients with PDD disorder (adult and child) may be as low as 10% per year, but the outcome is significantly better with active treatment.

Children whose parents have depressive disorders are as much as 3 times more likely to develop a mood disorder.

Anhedonia, or markedly diminished interest or pleasure, is a severity marker that should always alert the diagnosing clinician. It is always associated with the development of a more severe prognostic course.[4]

Morbidity

PDD causes severe and prolonged social, interpersonal, and academic dysfunction. If a child has a parent with a depressive disorder—children whose parents have depressive disorders are as much as 3 times likely to develop a mood disorder—the youngster may be exposed to an unstable home and stressful life events, increasing the risk for dysfunction even further.

Childhood PDD is associated with an increased risk for subsequent major depressive disorder and bipolar disorder, as well as a less likely, but still significant, increase in the risk for substance use disorders and anxiety disorders.

Approximately 70% of pediatric patients with PDD develop a superimposed major depressive disorder within 5 years. Fifty percent of pediatric patients with PDD have other psychiatric disorders as well, including anxiety disorders (40%), conduct disorder (30%), attention deficit hyperactivity disorder (ADHD; 24%), and elimination disorders (ie, enuresis, encopresis; 15%). Approximately 15% of pediatric patients with dysthymic disorder have 2 or more comorbid disorders.

Early onset PDD is associated with an increased risk of subsequent major depressive disorder and substance abuse. Indeed, depressed children are more likely to use tobacco, alcohol, and other substances in adolescence and adulthood. Increased mortality and morbidity are of course associated with these behaviors.

Comorbid conditions in patients with PDD need treatment, because they may influence the maintenance and recurrence of depression, lengthen the duration of depressive episodes, increase the risk of suicide, and increase the rate of mental health service use. Individuals with additional psychiatric disorders have poorer outcomes, poorer response to treatment, and more severe social impairment.

Mortality

PDD increases the risk for development of major depressive disorder, with its concomitant possibility for suicidal thoughts and suicide attempts. Children who have PDD along with an exacerbation of depressive symptoms, including recurrent suicidal ideation, may be diagnosed with major depression in conjunction with PDD.

Suicidal thoughts are not uncommon in preadolescent children with depression, although attempts are less common than in adolescents or adults and are less likely to be lethal. Community studies have shown 8.9% of preadolescent depressed children express suicidal ideas and 3% make threats or mild attempts.[5]

Among US adolescents, suicide is the third-ranking cause of death (rate of 7.4 cases per 100,000 population for the age range 15-19 years, rate of 1.2 cases per 100,000 population for the age range 10-14 years, rate of 4.3 cases per 100,000 for the age range 10-19 years), after accidents and homicide. Nearly one fourth of high school students in the United States report having considered suicide, approximately 18% acknowledged more serious intent by making a specific suicide plan, and nearly 8% have attempted suicide, with almost 3% requiring medical attention for associated injuries.[5]

Suicide rates vary according to sex and ethnicity, with American Indians/Alaska natives having roughly twice the rate of death by suicide than do whites, who have a rate roughly twice that of blacks and Asians/Pacific Islanders (8 cases per 100,000 population compared with 4.7 cases per 100,000 population and 2.5 cases per 100,000 population, respectively).

Males outnumber females in terms of death from suicide in all ethnic groups, with ratios ranging from 3:1 in Asian/Pacific Islanders to 4:1 in Native Americans to 5:1 in whites to almost 6:1 in blacks. The gender differences parallel those in adults; men are more likely than women to die from suicide attempts, due to use of more lethal means.

Although suicidality is not a predominant symptom in dysthymia, mood disorders are considered a spectrum disorder, and suicidal tendencies should be carefully assessed in all patients with depressive symptoms.

 

Presentation

History

The clinical history is crucial in making the diagnosis of persistent depressive disorder (PDD). Behavioral assessment in pediatric patients must take into account the patient's current developmental stage and often includes information from additional sources, mainly parents and teachers. (In addition to taking the patient’s history, conducting a thorough physical examination is important, to rule out medical illness as a cause of symptoms.)

In the case of all suspected depressive disorders, suicidal ideation, homicidal ideation, and a history of behavior in which the patient has harmed himself/herself or others must be assessed during the initial presentation and throughout the course of treatment. Although these symptoms are more closely associated with more severe diagnoses than dysthymia, given the comorbidities in psychiatric illness, these factors need to be considered throughout the clinical process.

DSM-5 criteria

Diagnostic criteria taken from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), from the American Psychiatric Association (APA) are as follows[1] :

  • A - Depressed (or irritable) mood for most of the day for more days than not as indicated by subjective account or observation by others for at least 1 year; in children, the parental report may emphasize behavioral difficulties expressing depression, whereas the child can give a better account of internalizing symptoms, including suicidal ideation

  • B - The presence, while depressed, of 2 (or more) of the following: (1) poor appetite or overeating, (2) insomnia or hypersomnia, (3) low energy or fatigue, (4) low self-esteem, (5) poor concentration or difficulty making decisions, and (6) feelings of hopelessness

  • C - During the 1-year period of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time

  • D - Criteria for a major depressive disorder may be continuously present for 2 years

  • E - No manic episode, mixed episode, or hypomanic episode is noted, and criteria have never been met for cyclothymic disorder

  • F - The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia, schizoaffective disorder, or delusional disorder

  • G - The symptoms are not due to the direct physiologic effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hypothyroidism)

  • H - The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Additional symptoms

Symptoms associated with PDD but not included in the formal diagnostic criteria are anger, feelings of being unloved, self-deprecation, anxiety, and disobedience.

The chronic course of PDD can contribute to academic, social, and behavioral disruption, with profound effects on psychological and educational development. Children and adolescents with PDD may develop more acute and intense depressive symptoms sufficient to meet the criteria for major depression.

Symptoms found primarily in children

Some symptoms of depressive disorders are more common in children than in adults. For example, irritability, social withdrawal, and somatic complaints (unexplained general medical complaints) are more likely to be observed in children. On the other hand, hypersomnia and psychomotor retardation are more common in adults. Children, particularly younger children, may display aggressive behavior and psychomotor agitation as aspects of PDD.

Persistent depressive disorder versus major depressive disorder

A considerable overlap of symptoms is observed between PDD and major depressive disorder, and the relationship between them is the subject of ongoing debate. However, PDD and major depressive disorder differ in terms of chronicity and pervasiveness.

 

DDx

Diagnostic Considerations

Conditions to consider in the differential diagnosis of persistent depressive disorder (PDD) disorder in pediatric patients include the following:

  • Reactive attachment disorder

  • Sexual abuse

  • Chronic fatigue syndrome

  • Conduct disorder

  • Anorexia

  • Bulimia

  • Encopresis

  • Enuresis

  • Failure to thrive

  • Fibromyalgia

  • Growth failure

  • Hyperparathyroidism

  • Hypokalemia

  • Hyponatremia

  • Hypopituitarism

  • Hypothyroidism

  • Malnutrition

  • Mononucleosis

  • Epstein-Barr virus infection

  • Bipolar disorder

  • Oppositional defiant disorder[6]

  • Avoidant personality

  • Schizophrenia

  • Nightmares

  • Conversion disorder

  • Pain

  • Somatization

  • Mood disorder due to a general medical condition

  • Alcohol-induced mood disorder

  • Substance-induced mood disorder

  • Alcohol or substance use or abuse

  • Personality disorder

  • Schizoaffective disorder

  • Bereavement

  • Adjustment disorder with depressed mood

  • Adjustment disorder with mixed anxiety and depressed mood

  • Depressive disorder not otherwise specified

  • Seasonal affective disorder

  • Growth retardation

  • Mixed language disorder

  • Stuttering

  • Hypochondriasis

Differential Diagnoses

 

Workup

Approach Considerations

Screening

The American Academy of Child and Adolescent Psychiatry (AACAP) recommends screening of children and adolescents for depressive symptoms; specifically, sad mood, irritability, and anhedonia. If these symptoms are present most of the time, affect the child's psychosocial functioning, or are greater than the expected level for the child's developmental stage, then further evaluation for the presence of depression should be undertaken.

Lab studies

Perform laboratory studies in patients with persistent depressive disorder (PDD) only when the history and physical examination suggest their relevance.

Imaging studies

Few, if any, studies use either structural (ie, computed tomography [CT] scanning, magnetic resonance imaging [MRI]) or functional (ie, positron emission tomography [PET] scanning, single-photon emission CT [SPECT] scanning, magnetic resonance spectroscopy [MRS]) in the diagnosis of dysthymia in pediatric patients.

Mental Health Evaluation

Assessment of PDD in children can be accomplished in several ways. The AACAP recommends a comprehensive mental health diagnostic evaluation as the single most useful tool in the diagnosis of depressive disorders.

Standardized diagnostic interviews, conducted by clinicians or lay examiners, are often used in research settings and have been psychometrically studied. Self-report questionnaires have been developed but serve mainly as screening tools and may not reflect diagnostic criteria for PDD. Likewise, ratings by teachers, parents, and peers may be helpful as part of the overall assessment of the depressed pediatric patient but, of course, are not sufficient to make a diagnostic determination.

According to the AACAP, a comprehensive mental health diagnostic evaluation consists of separate or conjoint interviews by a trained clinician with the patient and his or her parents or caregivers. Contact with other informants (eg, teachers, primary care physicians) is helpful. A mental status examination, modified as necessary for the patient's developmental age, should be part of the assessment.

Physical examination and, as noted above, laboratory tests as suggested by the physical examination are often helpful in ruling out general medical conditions that may produce depressive symptoms. In addition, the mental health professional should obtain information about the following:

  • Risk factors for suicidal or homicidal actions - Ie, age, sex, stressors, comorbid conditions, hopelessness, impulsivity

  • Protective factors for suicidal or homicidal actions - Eg, religious belief, concern about hurting family

  • Comorbid psychiatric diagnoses

  • Psychosocial problems

  • Academic problems

  • Recent and historical negative life events

  • Family psychiatric history and presence of family psychopathology

  • level of social support

  • Medical history

  • Current and past use of medications

  • Substance use

In addition, an assessment of global functioning will be useful in determining current impairment, if any, in life tasks.

Interview schedules

The Child Assessment Schedule (CAS), administered by a trained clinician, reliably and validly assesses PDD, as does the Interview Schedule for Children (ISC). Another widely used research scale, the Schedule for Affective Disorders and Schizophrenia in School-Age Children (K-SADS), does not assess dysthymia as a separate diagnostic category. Other structured interview schedules for use with lay interviewers do not differentiate PDD from generalized depression.

Self-report scales

Self-report measurement scales, such as the Children's Depression Inventory (developed from the Beck Depression Inventory) and the Reynolds Child and the Reynolds Adolescent depression scales, can be very helpful as screening tools. Moreover, when used as repeated measures, they have the advantage of also providing a means of assessing treatment response.

Indications of depression on self-report scales should be followed with a more thorough assessment by a physician or mental health professional. Multiple informants and multiple methods (eg, self-report, interview, observations) provide the most thorough picture of the extent of depression and of the level of functional impairment.

DesTeen

The Depression Screener for Teenagers (DesTeen) can be regarded as a valid screening tool for adolescent depression. It includes a self assessment and a diagnostic interview. The results of a shortened, 5-item version are particularly promising.[7]

 

Treatment

Approach Considerations

Various types of psychotherapy (psychodynamic, cognitive-behavioral, interpersonal, family therapy) have been the mainstay for treatment of persistent depressive disorder (PDD) in children and adolescents. Increasing emphasis has been placed on psychopharmacology in depressed pediatric patients.[8]

However, most of the recommendations for treatment with either psychotherapy or drugs are based on the adult literature. At the time of writing, controlled studies of different treatment strategies for major depressive disorder in the pediatric population have only begun to be conducted. Given the experience with adult patients indicating that effective treatments for major depression also work for PDD, the results from these current studies can probably inform treatment planning for children with PDD.

Because of the lack of research into the treatment of pediatric dysthymia, the American Academy of Child and Adolescent Psychiatry (AACAP) recommends that interventions that have been effective in treating major depressive disorder be used in children and adolescents with dysthymic disease.[9]

The chronicity of PDD (mean episode duration 3-4 years for community samples; duration at least 1 y to make the diagnosis) means that intense and long-term treatment may be necessary. This is particularly challenging given the arbitrary limits on insurance coverage for mental health diagnoses.

Activity

Encouragement of developmentally appropriate play, physical exercise, and pleasurable activities are appropriate for children with anhedonia. Physical exercise has been shown to improve mood. Active play or sports (if psychologically supportive, rather than an opportunity for criticism) can accomplish these aims.

Inpatient care

Inpatient care generally is not necessary for the treatment of PDD. If major depression develops with suicidal ideation, then inpatient care may be urgently needed.

Pharmacologic Therapy

Integration of psychotherapeutic and psychopharmacologic treatments is typical in the adult population suffering from PDD. In adults, studies have shown that tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) are helpful when administered at the same dosages used in the treatment of major depressive disorder.

However, most of the studies of treatment in the pediatric population have used psychotherapy as the primary treatment. Very few studies on the use of pharmacotherapy alone or on combined pharmacotherapy and psychotherapy with pediatric dysthymic patients are available.

Psychotherapy

Psychotherapy is used to teach patients and their families to cope with stress (current and historical), improve social skills and self-concept, understand themselves and their family, and deal with interpersonal and social conflict. In addition, it can help patients to deal with the familial, academic, and occupational problems associated with depression.

Psychodynamic psychotherapy, interpersonal therapy, cognitive behavioral therapy, behavior therapy, family therapy, supportive psychotherapy, and group psychotherapy have been used with depressed pediatric patients. Several factors appear to be related to the effectiveness of psychotherapy, including the following:

  • Age at onset of depression

  • Severity of depression

  • Presence of comorbid psychiatric disorders

  • Presence of or lack of support

  • Parental psychopathology

  • Significant family conflict

  • Exposure to stressful life events

  • Socioeconomic status

  • Quality of treatment

  • Therapist's expertise

  • Motivation of patient and therapist

Psychodynamic psychotherapy

Psychodynamic psychotherapy, informed by psychoanalytic thinking, has as its goals helping patients to understand themselves, identify feelings, improve self-esteem, change dysfunctional patterns of behavior, interact more appropriately with others, and manage past and ongoing conflicted relationships.

Interpersonal therapy

Interpersonal therapy focuses on interpersonal roles and difficulties. Grief, disputes, and role transitions are among the issues that may be dealt with in individuals with PDD. Improved interpersonal relationships may help to lessen the possibility of relapse after treatment.

Cognitive behavioral therapy

Cognitive behavioral therapy deals with the cognitive distortions present in the patients' views of themselves, others, and the world. This form of therapy systematically examines and counteracts these distortions, which contribute to the maintenance of depression. In the pediatric population, of course, intellectual and conceptual development may limit the usefulness of this technique.[10, 11]

Supportive psychotherapy

Supportive psychotherapy offers a nurturing environment for the expression of affect. In one study of adolescents, however, it was shown to be less effective than cognitive-behavioral therapy.

Group psychotherapy

Group psychotherapy, using various techniques, can be effective and efficient.

Ongoing Care

Given the chronic nature of PDD, ongoing psychotherapeutic and/or psychopharmacologic care may be necessary to foster sustained remission and modification of maladaptive coping. Termination of cognitive behavioral therapy and interpersonal therapy, when studied in the treatment of major depression in the pediatric population, resulted in a significant relapse rate on follow-up care, suggesting the need for maintenance therapy.

Jonsson et al concluded that depression in adolescence is a good predictor of adult depression and encouraged investigation into early interventions that might alter this pattern.[12]

Deterrence and Prevention

Very few studies have been published on the prevention of depressive disorders in general in children and adolescents. Given the lengthy course of PDD, however, prevention and early intervention are key to minimizing suffering and functional impairment.

PDD is often followed by recurrent major depression; prevention and early treatment of PDD could help to prevent this more serious condition, as well as other potential future comorbidities, such as substance abuse and school failure.

The few studies that have been conducted show that group cognitive behavioral therapy, together with relaxation training and group problem-solving therapy, may prevent recurrences of subclinical depression for many months posttreatment.

Although long-term data are unavailable, brief, family-based educational interventions have also helped to prevent mood disorders in children at risk because of parental depression.

Suicide risk

Adolescent patients with PDD may develop a superimposed major depressive episode and deteriorate quickly into a more severely ill state. Such a change may be overlooked by the patient, who sometimes becomes accustomed to the chronically depressed state and may not differentiate development of an acute major depressive episode from the baseline. The emotional lability of adolescents and the intensity of their developmental state and relationships may provide sufficient stress to potentiate an impulsive suicidal act.

Unfortunately, many patients who attempt or complete suicide have seen a health care practitioner within a relatively short period before their suicide attempt. Frequent assessment of suicidal ideation and other depressive symptoms can assist the clinician in intervening appropriately. Suicide attempts are a psychiatric emergency and should be treated as such, with intensive assessment and intervention; this includes hospitalization if the patient’s safety cannot be ensured on an outpatient basis.

Consultations

Psychotherapeutic treatment generally requires the pediatrician to make a referral to a trained mental health clinician. Child clinical psychologists, child and adolescent psychiatrists, behavioral-developmental pediatricians, child-trained clinical social workers, and professional counselors are resources for the pediatrician who encounters dysthymic patients.

Given the paucity of data clearly showing pharmacologic intervention in children with PDD to be safe and effective, psychosocial interventions are often tried before psychopharmacologic treatment is considered. When medication is considered, consultation with a psychiatrist or behavioral pediatrician is required.

 

Medication

Medication Summary

According to the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters, few studies are available to inform the use of antidepressant medication in children with persistent depressive disorder (PDD). However, studies of adult patients with PDD have shown that tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) are effective in treating PDD at the same doses that are effective against major depressive disorder.

"[B]ased on the limited adult literature, efficacious treatment for [major depressive disorder] may also be useful for the management of [PDD]," states the AACAP.[9] However, the US Food and Drug Administration (FDA) has approved only a handful of the multiple drugs in the first 2 of the above 3 classes for use in depression (or for other indications) in children and adolescents.

Because most medications administered to children have not been extensively studied in the pediatric population, the information below is given with the understanding that this use reflects current practice among child and adolescent psychiatrists. As a patient's age approaches adolescence, the physician can be more confident that the treatment is likely to be as effective as it is for the disorder in adulthood.

Current consensus is that SSRIs are greatly preferred over the other classes of antidepressants. The adverse effect profile is less prominent, promoting compliance. SSRIs are also much safer from a medical standpoint, without the risk of cardiac arrhythmia observed in TCAs. Such a risk is especially pertinent in overdose; suicide risk always must be considered in the treatment of a child or adolescent with a mood disorder.

Selective Serotonin Reuptake Inhibitors

Class Summary

SSRIs are antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit central nervous system (CNS) neuronal uptake of serotonin (5HT). They may also have a weak effect on norepinephrine and dopamine neuronal reuptake.

Increasing controversy surrounds the use of SSRIs in the pediatric population. In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, with the exception of fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.[13]

In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications for major depressive disorder (not dysthymic disorder). This advisory reported suicidality (ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. Nonetheless, the FDA has asked that additional studies be performed because suicidality occurred in treated and untreated patients with major depression and thus could not be linked to drug treatment.[14]

In March 2004, the FDA issued a public health advisory regarding several antidepressant medications, partly in response to their use in the pediatric population. For more information, see the FDA advisory statement on worsening depression and risk of suicidality with antidepressant drugs.[15]

After the initiation of medical treatment, physicians are advised by the FDA to closely monitor patients for worsening depression or suicidality and for signs of mania or hypomania development. Furthermore, the FDA advisory specifically states that health care providers should instruct patients, families, and caregivers to be alert for the emergence of suicidality, worsening depression, agitation, irritability, and other symptoms (eg, anxiety, panic attacks, insomnia, hostility, impulsivity, akathisia, hypomania, mania) and to immediately report such symptoms to the health care provider.

In October 2004, the FDA issued a public health advisory intended to warn the public about the risks of increasing suicidality among adolescents and children treated with antidepressants. The FDA’s efforts included the requirement of a "black box" warning on medication labeling directed to prescribers and the development of patient information materials to inform consumers of the potential risks of suicidal behavior in depressed pediatric patients. For more information, see information specific to certain antidepressants from the FDA.

According to a report by Cheung et al, prescribing of antidepressants by pediatricians (psychiatrists were not part of this study) decreased after the FDA issued the black box requirement.[16]

However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found a decline, rather than a rise, in suicide risk with the use of antidepressants.[17] This is the largest study to date to address this issue.

Currently, evidence does not exist to associate an increased suicide risk with the treatment of obsessive-compulsive disorder (OCD) or other anxiety disorders with SSRIs.

Note that fluoxetine is the only medication approved by the FDA to treat depression in children aged 7 years and older. Other medications are used off-label.

The FDA's recommendations are sound with regard to the treatment and monitoring of all patients with mood disorders, whether or not medication is used. Because treatment response and the course of the illness vary, ongoing monitoring for increasing severity of the illness and the development of more intense symptoms is wise.

Physicians are advised to be aware of the above information and to use appropriate caution when considering treatment with antidepressant medications in the pediatric population.[18]

Fluoxetine (Prozac)

Fluoxetine is FDA approved for depression in children 7-17 years. The drug, which has a half-life is of 7-9 days, selectively inhibits presynaptic serotonin reuptake.

Sertraline (Zoloft)

Sertraline is FDA approved for the treatment of OCD in children aged 6 years and older. It is also used off label for depression in children. The drug selectively inhibits presynaptic serotonin reuptake.

Fluvoxamine (Luvox)

Fluvoxamine is FDA approved for OCD in children older than 8 years. It is also used off label in children for depression. The drug selectively inhibits presynaptic serotonin reuptake.