Clinical practice guidelines for the management of depression in children and adolescents

Abstract

INTRODUCTION Over the last half century, it is now well established that depression can occur at any age, and it has been documented as early as infancy. In terms of epidemiology, different studies which have evaluated the prevalence of depression in children and adolescents suggest that the prevalence varies according to the different age groups. Prevalence figures reported for infants vary from 0.5% to 3% in clinic population, whereas in preschool children, the prevalence rate for major depression (1.4%) has been reported to be higher than depression not otherwise specified (0.7%) and dysthymia (0.6%). Studies done in community settings suggest the prevalence of depression in children to range from 0.4% to 2.5% and among adolescents to be from 0.4% to 8.3%. Lifetime prevalence through adolescence is considered to be as high as 20%. Prior to puberty, depression is known to have equal gender representation; however, among adolescents, the male: female ratio is 1:2. Over the years, it has also been understood that depression in children and adolescents is a chronic and relapsing condition, which does not remits spontaneously and hence, there is a need to identify and treat the same at the earliest to reduce its long-term negative consequences. Childhood depression has been shown to lead to an increased risk of poor academic performance, impaired social functioning, suicidal behavior, homicidal ideation, and alcohol/substance abuse. It is also associated with an increased risk of recurrent depressive episodes. Unfortunately, a major proportion of depression in children and adolescents is underdiagnosed and undertreated. SCOPE OF THE GUIDELINES The Indian Psychiatric Society published clinical practice guidelines for the management of depression in children and adolescents for the first time in the year 2007. Over the years, more research has accumulated in this area, and hence an effort is made to update the previous version of the clinical practice guidelines. These guidelines intend to provide a broad framework for the proper assessment and management of depression in children and adolescents. It is recommended that these guidelines must be read with the previous version. These guidelines must not be considered as a substitute for the professional knowledge and clinical judgment of the treating psychiatrist. It is important to remember that these guidelines are not applicable to any specific treatment setting and will require minor modification to suit to the needs of the children and adolescents in various treatment settings. Accordingly, the recommendations made as part of this guideline may have to be tailored to the needs of the individual patient. ASSESSMENT OF DEPRESSION IN CHILDREN AND ADOLESCENTS Assessment of depression in children and adolescents involves establishing the diagnosis; evaluating comorbid conditions; considering all the possible differential diagnoses; and evaluating psychosocial issues contributing to the development and continuation of depression such as family discord, family psychopathology, suicidal risk, and the ensuing dysfunction. It also involves developing a good therapeutic alliance with the children and adolescents and their family members and making decision about treatment setting and patient's safety. Assessment needs to be understood as an ongoing process and patients may have to be assessed regularly, as per the need and phase of the treatment [Table 1].Table 1: Assessment of children and adolescents presenting with depressionHistory Taking: The complete psychiatric evaluation should include a history of the present illness and current symptoms; evaluation for symptoms of mania or hypomania, taking history, and evaluation for general medical conditions; evaluation for a history of substance use disorders; evaluation for a personal history (e.g., psychological development, response to life transitions, and major life events); evaluation for a social, educational, and family history; and a review of the patient's medications, past treatment history, physical examination, detailed mental status examination, and diagnostic tests as indicated. In general, for identification of depression in children and adolescents, it is better to collect information from all the possible sources, i.e., report and observation of patients, parents, peers, siblings, and teachers during the clinical interview. It is important to remember that the child and parents or other caregivers need to be interviewed separately and also together. Usually, more than one interview may be required to get the complete picture of It is that evaluation of children with depression should interview of the parents and the are in the and of depressive more report symptoms such as whereas children more report symptoms such as needs to be and the mental status examination, can be as part of the It is reported to and children, preschool children with depression and more in such as of and with the with depression a