2. Introduction
• It comes under the broad category of
affective and emotional disorders of
childhood & adolescents
• Includes childhood depression, anxiety
disorders, adjustments disorders, PTSD &
OCD.
• Childhood depression widely vary from adult
depression.
• More
recurrent,
causing
significant
psychosocial
impairment
&
scholastic
functions.
• Difficult to treat when suicidal ideations exist.
3. Epidemiology
• Prevalence
rates
raises
through
adolescence with estimates in preadolescents of the order of 0.5-2.5%
increasing up to 8% in adolescents.
• Recurrence of depression within 5 years is
70%
• 50% developed to have recurrent
depression in the adulthood
• After 15 yrs, girls are twice more risk than
boys to develop depression.
4. Suicidal intent
• Depression is associated with high risk of suicidal behavior
among adolescents.
• For every fatality there are at least 100 attempts.
• Suicidal risk is high with depressed boys who have comorbid disorders such as CD or SUD’s
• Among adolescents who develop MDD, 7% may commit
suicide (NIMH report-1997).
• 2% of high school students have made suicide attempts
that have come to medical attention, with larger numbers
making less serious attempts (Indian Report).
• Completed suicide occurs in about 1/100 000
preadolescents and 13/100 000 adolescents, with boys
exceeding girls by 4 to 1.
5. Risk factors
• Biomedical factors
–
–
–
–
–
–
Chronic illness (e.g., diabetes)
Female sex
Hormonal changes during puberty
Parental depression or family history of depression
Presence of specific serotonin-transporter gene variant
Use of certain medications (e.g., isotretinoin [Accutane])
• Psychosocial factors
– Childhood neglect or abuse (physical, emotional, or sexual)
– General stressors including socioeconomic deprivations
– Loss of a loved one, parent, or romantic relationship
• Other factors
–
–
–
–
–
Anxiety disorder
Attention-deficit/hyperactivity, conduct, or learning
disorders
Cigarette smoking
History of depression
6. Clinical features of depression
• Sad mood or loss of interest or pleasure.
• Irritability.
• Loss of weight, marked change in sleep pattern,
loss of appetite.
• Psychomotor agitation or retardation (inability to sit
still, temper tantrums or inability to get started are
characteristic).
• Reduction in energy levels, fatigue, and boredom.
• Feelings of worthlessness or guilt (in children and
young people this is usually attributed to what
others think of them).
• Continues ….
7. • Impaired thinking, concentration or
decision making with deterioration in
schoolwork and school refusal.
• Anhedonia (an inability to enjoy
pleasurable activities).
• Social withdrawal.
• Combativeness with parents.
• Loss of interest in schoolwork.
• Delinquent behaviour.
• Recurrent thoughts of death or suicide.
8. • Psychotic depression
– Associated with apparent loss of reality
– Delusions or hallucinations, with a depressive
and self-critical or self punitive content, are
prominent
• Bipolar disorders
– Occasional elevation in mood status such as
excitability, irritability, excess energy, lack of
judgment, and disinhibition.
9. Differential diagnoses
•
•
•
•
•
•
Normal reactive feelings of sadness
Anorexia nervosa
Severe anxiety
Disruptive disorder
ADHD
Medical disorders such as epilepsy, systemic lupus
erythematosus, traumatic brain injury, space occupying lesion,
endocrinopathies, and dementias
• Adverse drug reactions, for example clonidine, stimulants and
steroids
• Substance abuse (in particular ecstasy, amphetamines,
barbiturates, and cocaine)
• Psychosis.
10. Risk factors for completed suicide and
suicide attempts
Suicidal ideation and/or
attempts
• Females
• Previous suicide attempt
and ideation
• Major or minor depressive
disorder
• Substance abuse
• Antisocial behaviour
• Undesirable life events
• Problems with
parents, partners, school, or
work Loss in males
• Sexual or physical abuse
Completed suicide
•
•
•
•
•
•
•
•
•
Males
Previous suicide attempt and
ideation
Familial psychiatric disorder and
completed suicide attempt.
Mood disorder—60%
Alcohol or drug abuse
(particularly in males)
Antisocial behaviour
Acute life crisis
Disciplinary crisis/dispute with
friend or parent
Legal or disciplinary problems in
past year
11. Warning signs for suicide behaviour
– In short term;
•
•
•
•
•
•
•
•
Thoughts of suicide as a solution to a problem
References to suicide in conversation
Disciplinary crisis or expulsion from school
Preparation in the form of writing a will or a final
message
Increase in help seeking behaviour
Improvement of mood directly beforehand
During the early stages of treatment the patient is
particularly vulnerable to suicide
Recurrence of a situation that preceded a previous
attempt of self-harm
12. – In longer term;
• Psychiatric morbidity
• Previous suicide attempts of patient or parent
especially when accompanied by a strong desire
to die
• Recent losses
• Hopelessness
• Lack of confiding friend and isolation
• Learning disorder or academic underachievement
• History of violent or impulsive behaviour
• Social disadvantage: broken home, unwanted
pregnancy, conflict with parents, sexual, and
physical or emotional abuse.
– Sexually abused girls are 20 times more likely and sexually
abused boys 40 times more likely to commit suicide
13. Management
• Encourage the child to avoid;
– Alcohol, illegal drugs, sleep deprivation,
academic & work pressure, or pretending that
nothing is wrong.
• Encourage the parents to avoid;
– Self-blame
– Exhaustion
– Psychological cause hunting
14. Psychopharmacology
• The first line drugs used are selective
serotonin reuptake inhibitors & the new
reversible monoamine oxidase inhibitors
(RIMAs).
• SSRIs are on the whole well tolerated and
present minimal danger in overdose
• Second line medications include venlafaxine
and nefazadone
• TCA’s are not recommended for the
treatment of depression in this age group as
they are less effective, have unpleasant side
effects, and are dangerous in overdose
15. Psychosocial therapies
• Interpersonal: relieve symptoms through
resolution of interpersonal problems and
improved social adaptation (role playing)
• Analytic: personality reorganization,
adoption of mature defences, realistic sense
of self and resolve past traumas if any
(development of transference relationships
which helps in the development of insight.
• Play: to understand wishes, fantasies &
traumas. Discharging feeling via physical
activities.
16. • Behavioral: reduced positive
reinforcement from environment which
produces stimulus for depression
(modeling/shaping for appropriate prosocial behavior)
• Family: positive reframing decrease
blaming and scapegoating, altering
unhealthy family rules, recognizing crossgenerational dynamics.
• School based: diagnose & address spl
needs rltd to language or learning
difficulties, social inadequacies, etc. by
altering class room envmnt or mode of
