For acute depression, more frequent visits are indicated, and the risks of medication (including suicidal and self-destructive behavior) should be discussed with parents, guardians, and patients. Higher frequency of monitoring can include phone calls or collaborative care with a psychotherapist. Parents and patients should also be educated about warning signs and to call immediately if these new symptoms occur. Notable side effects are thoughts of suicide, increased agitation, or restlessness. Other side effects include headache, dizziness, gastrointestinal symptoms, sleep cycle disturbance, sexual dysfunction, akathisia, serotonin syndrome, and risk of increased bruising (due to platelet inhibition.) There is also a risk of SSRI-induced mania.
In 2004 the FDA issued warnings for all antidepressants regarding suicidal thinking or behavior. The data suggest that antidepressants pose a 4% risk, versus a 2% risk in placebo. An increase in suicides in children and adolescents since that year has many experts believing that it might be related to low prescription of antidepressants and resultant untreated depression. Substance use, concomitant conduct problems, and impulsivity increase the risk of suicide.
Psychotherapy appears to have good efficacy in mild to moderate depression. In moderate to severe depression, combinedtreatment with psychotherapy and medication has the greatestrate of response, although in severe cases the efficacy was equivalent to medication alone. Cognitive-behavioral therapy andinterpersonal therapies are the empirically supported psychotherapies. Cognitive behavioral therapy and its derivative, dialectic behavioral therapy (for borderline personality disorder),involve techniques and skills-building to mitigate cognitivedistortions and maladaptive processing; whereas interpersonaltherapy focuses on collaborative decisions between the therapist and patient and is based on the exploration and recognition of precipitants of depression. Family therapy is often usedas an adjunct to other treatments for depression.
Light therapy has been shown to be beneficial for seasonal affective disorder and in MDD with a seasonal component. Electroconvulsive therapy is used in refractory and life-threatening depression.
Depression is a chronic and debilitating illness that often starts in childhood or adolescence. It increases risk for future suicide, substance use, and other psychiatric sequelae. Adolescent depressive disorders are more likely to be recurrent into adulthood than childhood onset depression.
Suicide is a fatal complication of MDD and surpasses motor vehicle accidents as a cause of death in adolescents. It has high prevalence among high school students with 20% having contemplated suicide and 8% having attempted each year. While the risk of suicide during an MDD episode is high, it can be paradoxically higher during start of treatment as energy and motivation improve with cognitive recovery from depression.
Treatment is targeted toward decreasing morbidity and suicide. Along with treatments mentioned previously, modalities such as hospitalization, partial hospital, therapeutic after-school programs, or psychoeducation may be needed.
Bipolar disorder consists of distinct periods of mania (elevated, expansive, or irritable moods and distractibility) that may alternate with periods of severe depression (Table 18-2).
To diagnose mania associated with BD, euphoria (elevated or expansive mood) and three additional symptoms; or irritability and four additional manic symptoms are required. Children and adolescents with euphoric mood are bubbly, giggly, and “over-the-top” happy, to a degree that is socially unacceptable to others. Grandiosity in children is often dramatic. Children act as if they are superior even when it is obvious that it is not true, and they behave as if the laws of nature do not apply to them. Racing thoughts are common in BD. Periods of extreme rage also are common. Children with BD often present with rapid or ultra-rapid cycling with multiple shifts between euthymia, mania, and depression.