Overview of Prevention and Treatment For Pediatric Depression - UpToDate

11/30/2020 Overview of prevention and treatment for pediatric depression - UpToDate
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Overview of prevention and treatment for pediatric

depression
Authors: Liza Bonin, PhD, C Scott Moreland, DO
Section Editors: David Brent, MD, Diane Blake, MD
Deputy Editor: David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2020. | This topic last updated: Feb 09, 2020.
INTRODUCTION
Pediatric depression typically presents in primary care and is undertreated [1,2]. Multiple
studies in the United States, including a nationally representative surveys [3,4] and retrospective
studies of an administrative claims database [2] and medical records [5], indicate that roughly
40 percent of children and adolescents with depressive disorders are not treated.
Among children and adolescents with depression who receive standard treatment,
psychotherapy alone is used most often [2,5]. The second most frequently used treatment is
medication monotherapy and the least used is psychotherapy plus an antidepressant.
This topic provides an overview of treating pediatric depression. Pharmacotherapy and

psychotherapy for juvenile depression, as well as the assessment, diagnosis, and differential
diagnosis of depression, are discussed separately.
● (See "Pediatric unipolar depression and pharmacotherapy: General principles".)
● (See "Pediatric unipolar depression and pharmacotherapy: Choosing a medication".)
● (See "Pediatric unipolar depression: Psychotherapy".)
● (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and

diagnosis".)
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DEFINITION OF UNIPOLAR MAJOR DEPRESSION
Unipolar major depression (major depressive disorder) is diagnosed in patients who have
suffered at least one major depressive episode ( table 1) and have no history of mania (
table 2) or hypomania ( table 3) [6]. A major depressive episode is a period lasting at least
two weeks, with five or more of the following symptoms: depressed mood, anhedonia, insomnia
or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low
energy, poor concentration, thoughts of worthlessness or guilt, and recurrent thoughts about
death or suicide. In addition, the symptoms must cause clinically significant distress or
impairment in functioning, and the syndrome is not due to the physiologic effects of a
substance (eg, drug abuse or medications) or another medical condition (eg, hypothyroidism).
(See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis",
section on 'Unipolar major depression'.)
Severity — The severity (intensity) of unipolar major depression is often classified as either mild
to moderate or severe.
Mild to moderate major depression is characterized by clinical features such as:
● No suicidal or homicidal ideation or behavior, or ideation that does not pose an imminent
risk (eg, thoughts that family members would be better off if the patient was dead; or
fleeting thoughts of killing oneself, with nonexistent or vague plans to commit suicide and
no intent).
● No psychotic features (eg, delusions or hallucinations).
● Little to no aggressiveness.
● Intact judgement such that the patient or others are not at imminent risk of being harmed.
Mild to moderate major depression is indicated by a score <20 points on the self-report Patient
Health Questionnaire – Nine Item (PHQ-9) ( table 4) [7,8]. Patients with mild to moderate
depression can generally be treated in an outpatient or partial (day) hospital program setting.
Severe unipolar major depression is characterized by seven to nine depressive symptoms that
occur nearly every day, as indicated by a score ≥20 points on the PHQ-9. Severely ill patients
often report suicidal ideation and behavior, typically demonstrate obvious impairment of
functioning, are more likely to develop complications such as psychotic features, and are
typically referred to a psychiatrist for management and inpatient hospitalization.

In addition, the PHQ-9 classifies patients as moderately severe if their score is 15 to 19. Patients
with moderately severe major depression require urgent attention and often require treatment
in either a partial hospital program or on an inpatient unit.
PREVENTION
Administering psychotherapy to children and adolescents in targeted populations can prevent

onset of depressive disorders [9]. However, the benefits are small and do not appear to last
beyond one year.
Targeted (selected) populations — Targeted treatment with psychotherapy to prevent either

new or recurrent onset of depressive syndromes includes children and adolescents who are at
high risk for the disorder by virtue of factors that include subsyndromal depressive symptoms,
death of a parent, family conflict, or family history of depression [9]. We generally do not
administer psychotherapy to prevent depressive disorders in at-risk youth, unless the individual
has suicidal ideation or behavior, a comorbid psychiatric disorder, functional impairment, has
previously had a depressive syndrome, or requests treatment. Nevertheless, it is reasonable to
provide psychotherapy even in the absence of these five exceptions, or to monitor at-risk youth
regularly (eg, once per month). (See 'Monitoring' below.)
Evidence regarding the use of psychotherapy to prevent depressive disorders includes a

systematic review that performed a meta-analysis of 22 randomized trials, which compared
psychotherapy with control conditions in children and adolescents (n >3900) who did not meet
criteria for a depression diagnosis [9]. The youth were at risk for developing depressive
syndromes due to the presence of subthreshold, mild to moderate depressive symptoms. Active
treatment consisted of cognitive-behavioral therapy or interpersonal psychotherapy, and
control conditions consisted of usual care or no treatment. Most of the trials were conducted in
school settings and delivered either group or individual therapy, usually on a weekly basis for 8
to 12 sessions. Diagnosis of a depressive disorder for up to 12 months after randomization was
less likely with psychotherapy than control conditions; however, the clinical effect was small and
did not persist beyond one year, and none of the trials controlled for psychotherapy’s
nonspecific effects, such as attention.
In addition, the systematic review performed a second meta-analysis, which aggregated four
trials (n >400 at-risk youth) that were not included in the first meta-analysis, and compared
psychotherapy with control conditions consisting of an attention placebo (eg, psychoeducation
about general mental and/or physical health) [9]. Self-reported depressive symptoms post
intervention were comparable for the two groups.

Universal (unselected) populations — We do not suggest universal prevention for depressive

disorders in children and adolescents. Universal prevention involves administering
psychotherapy to the population regardless of risk for the disorder, and is not effective. In a
meta-analysis of 10 randomized trials that compared either cognitive behavioral therapy or
interpersonal psychotherapy with control conditions in children and adolescents (n >2000), the
incidence of depressive disorders was comparable for the two groups [9].
GENERAL PRINCIPLES OF TREATING YOUTH WITH MAJOR DEPRESSION
Patient safety and treatment setting — The first step in acute phase treatment addresses
potential safety concerns. Every depressed child and adolescent must be evaluated for suicide
risk and if risk is identified, safety must be assured by choosing the right setting. (See "Suicidal
ideation and behavior in children and adolescents: Evaluation and management".)
Treatment of pediatric depression may occur in a variety of settings: outpatient, partial hospital,
inpatient, or residential [10]. Treatment should be provided in the least restrictive setting that is
safe and effective for a given patient. The setting depends upon the severity of illness (including
safety status), level of parental support, and motivation for treatment.
Treatment plan — Treatment planning should be collaborative with patients and their families
[11]; successful treatment typically requires parental involvement and cooperation [10].
Clinicians (eg, pediatricians, psychiatrists, or psychologists) who are treating youth with major
depression and are formulating a treatment plan should engage the parents to weigh the risks
and benefits of the various interventions (eg, psychotherapy and/or pharmacotherapy) in
deciding upon a treatment regimen. Involving the school may also helpful, depending upon the
severity of symptoms and impairment in the school setting.
The plan specifies the choice of therapy and frequency of sessions based upon the severity of
depressive symptoms, the age and developmental status of the patient, the degree of current
exposure to negative life events, and comorbidity (eg, anxiety and substance use disorders)
[10]. Many guidelines suggest a minimum of eight weeks of treatment for an acute episode of
major depression [12]. Multiple sessions per week may be needed during the acute treatment
phase. In addition, the plan should include interventions directed at problems in the patient’s
environment.
The plan also addresses the use of medication. (See "Pediatric unipolar depression and
pharmacotherapy: General principles".)

Education and resources — An important component of treating depression in youths is

education of patients and family members about the signs and symptoms of depression,
treatment options and their benefits and risks, prognosis, and the ways in which the illness has
affected their personal interactions [10-17]. With education, nonadherence with treatment may
decrease, and patients and family members may view depression as an illness, which can
reduce feelings of stigmatization and provide relief. Psychosocial difficulties may then be easier
to address. Education may also help family members identify their own depressive symptoms
and need for treatment [10,13,14].
Education addresses the:
● Signs and symptoms of depression ( table 1), using language that is developmentally
appropriate for the patient's level of understanding. (See "Pediatric unipolar depression:
Epidemiology, clinical features, assessment, and diagnosis".)
● Clinical course of depression, including the likelihood of relapse and recurrence (see
'Clinical outcomes' below). Knowing the clinical features of depression can help patients and
families recognize relapse early in its course.
● Impact of depression upon family and peer relationships, school attendance, and academic
functioning. (See "Pediatric unipolar depression: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Functional impairment'.)
● Use of pharmacotherapy. (See "Pediatric unipolar depression and pharmacotherapy:

General principles", section on 'Education'.)
● Use of psychotherapy. (See "Pediatric unipolar depression: Psychotherapy", section on

'General principles'.)
● Role of parents and teachers in treatment.
● Patient’s safety and plans for limiting access to means for self-harm (eg, dangerous
medications and weapons), particularly when there are concerns about suicidal or
homicidal ideation, plans, and intent [18,19]. (See "Suicidal ideation and behavior in children
and adolescents: Evaluation and management".)
Additional information for parents and adolescents about depression in adolescents is

discussed elsewhere in this topic. (See 'Information for patients and families' below.)
Resources for clinicians, patients, and families regarding treatment of depression in children
and adolescents include the following:

● American Academy of Child and Adolescent Psychiatry (www.aacap.org)
● United States Food and Drug Administration

(www.fda.gov/Drugs/ResourcesForYou/default.htm)
● The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit

(http://www.glad-pc.org)
● American Psychiatric Association (www.psych.org)
● American Psychological Association (www.apa.org)
● National Alliance for the Mentally Ill (www.nami.org)
● National Institute of Mental Health

(www.nimh.nih.gov/health/topics/depression/index.shtml)
● Mental Health America (http://www.mentalhealthamerica.net)
● Resources for integrated health care (see 'Collaborative care' below)
Collaborative care — Collaborative (integrated) care involves pediatric primary care clinicians

and mental (behavioral) health clinicians working together in the primary care setting to
diagnose and treat depressive disorders in children and adolescents [20-29]. Patients are
treated by a team that usually includes a primary care clinician, a case manager who provides
support and outreach to patients, and a mental health specialist (eg, psychiatrist) who provides
consultation and supervision. Other elements include a structured treatment plan that involves
pharmacotherapy, psychotherapy, or both; scheduled follow-up visits; communication amongst
the members of the treatment team; and measurement-based care. Collaborative care is used
for treating pediatric patients with mild to moderate episodes of unipolar major depression, as
well as severe episodes and/or treatment resistant episodes, and is used for patients managed
by pediatricians or family medicine clinicians who lack experience with major depression.
Instituting collaborative care to integrate the general medical and mental health of patients is
endorsed by the American Academy of Child and Adolescent Psychiatry and the American
Academy of Pediatrics. Measurement based care is discussed elsewhere in this topic. (See
'Monitoring' below.)
Multiple collaborative care programs, resources, and guidelines are available. As an example,
the clinical practice guideline, Guidelines for Adolescent Depression in Primary Care
(http://www.thereachinstitute.org/guidelines-for-adolescent-depression-primary-care),
incorporates consultation and coordination of care with mental health specialists as one of its
major tenets [11,30]. This guideline provides a toolkit that includes rating scales to aid in the
assessment and diagnosis of pediatric depression, information on various treatment options,

an algorithm/flowchart for management of depression, and educational materials.
Videoconferencing and web based approaches may aid collaborative care [31].
Major depression is often identified in the primary care setting, and primary care clinicians
manage the majority of depressed patients rather than referring patients to specialists such as
psychiatrists or psychologists [11,20,32-39]. However, many primary care providers think that
their training, support, or reimbursement for managing depressed youths is insufficient [36],
and that time constraints interfere with gathering an adequate psychiatric history [12]. These
problems may result in inadequate treatment.
Given that suicide is associated with undertreated pediatric depression [40-43], primary care
clinicians and mental health clinicians (eg, child psychiatrists, psychologists, and clinical social
workers) are encouraged to collaborate to surmount barriers that prevent appropriate care.
This may include brief consultations with mental health clinicians about individual patients, or
identifying a mental health clinician who is willing to see more severely ill patients on relatively
short notice [12].
Resources for integrated health care include the following:
● Integrated Primary Care; AAP Children's Mental Health in Primary Care, E-Newsletter
(https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-
Health/Pages/Collaborate-with-Mental-Health-Pro.aspx).
● Hogg Foundation for Mental Health Integrative Care Initiative; Connecting Body & Mind: A
Resource Guide to Integrated Health Care in Texas & the US – This report describes
integrated health care and identifies resources to assist with developing and implementing
integrated care systems. The online version is updated regularly with new information
(http://utw10282.utweb.utexas.edu/wp-content/uploads/2015/09/Connecting-Body-and-
Mind.pdf).
● A Resource Guide for Clinicians: Integrating Child and Adolescent Mental Health into
Primary Care; published by Texas Medical Association (www.texmed.org/Template.aspx?
id=3777).
● The Massachusetts Child Psychiatry Access Project (MCPAP, www.mcpap.org) provides

primary care clinicians with timely access to child psychiatry consultation, and includes
regional coordinators who identify appointment availability to psychiatrists and mental
health practitioners. Many pediatric clinicians in Massachusetts have joined this program.

Evidence for the efficacy of integrated health care includes a meta-analysis of five randomized
trials that compared collaborative care with usual care in children and adolescents (n >1000)
with depression or behavior problems [44]. Improvement was greater with collaborative care
and the clinical benefit was moderate to large. However, heterogeneity across studies was large.
In addition, one randomized trial indicates that collaborative care for adolescents with major
depression is cost effective [45]. Indirect evidence for the benefit of collaborative care includes
numerous studies in adults who were treated for major depression in primary care settings.
(See "Unipolar depression in adult primary care patients and general medical illness: Evidence
for the efficacy of initial treatments", section on 'Collaborative care'.)
Indications for referral — Although pediatric major depression is often treated successfully by

primary care clinicians, referral to a psychiatrist is sometimes necessary [12]. Indications for
referral include [30,46,47]:
● Uncertainty about the diagnosis of major depression
● Discomfort managing pediatric depression
● Current agitation, suicidal or homicidal behavior, history of suicide attempt, or inability of

the family to monitor the safety of the child or adolescent (see "Suicidal ideation and
behavior in children and adolescents: Evaluation and management")
● Psychotic features (eg, delusions or hallucinations) (see "Unipolar major depression with
psychotic features: Epidemiology, clinical features, assessment, and diagnosis" and
"Unipolar major depression with psychotic features: Acute treatment")
● Bipolar depression (see "Pediatric bipolar disorder: Clinical manifestations and course of
illness" and "Bipolar disorder in children and adolescents: Assessment and diagnosis")
● Acute comorbid disorders such as conduct disorder or eating disorders, or when other
comorbid disorders (eg attention deficit hyperactivity disorder, anxiety disorders, or
substance use disorders) are not amenable to treatment in primary care settings or not
responding to treatment
● Recurrent or chronic (eg, ≥2 years) depression
● Severe functional impairment or psychosocial stressors (eg, a high level of family discord)
● Lack of response to the initial course of treatment, despite using therapeutic doses for a
sufficient length of time (see 'Treatment resistant depression' below)

● Administration of psychotherapy (eg, cognitive-behavioral therapy or interpersonal therapy)

(see "Pediatric unipolar depression: Psychotherapy"). Psychotherapy should be
administered by properly trained clinicians; these can include psychiatrists, psychologists,
social workers, and nurses.
After a referral is initiated, we suggest that primary care clinicians continue to monitor patients
while they wait for the referral appointment. Primary care clinicians and psychiatrists (or other
mental health clinicians who are administering psychotherapy) should communicate about the
specific responsibilities for ongoing patient management [12].
Monitoring — We suggest that clinicians (eg, pediatricians, psychiatrists, or psychologists) who

are treating patients for depression regularly monitor outcomes with a brief scale completed by
patients (when feasible) and their parents to track progress and inform treatment adjustments
[12]. Limited evidence in adults suggests that monitoring depressive symptoms with a
standardized scale may improve treatment outcomes. However, there is no evidence that using
such scales improves outcomes in pediatric depression. (See "Pediatric unipolar depression and
pharmacotherapy: General principles", section on 'Monitoring' and "Using scales to monitor
symptoms and treat depression (measurement based care)", section on 'Evidence of efficacy'.)
We recommend using the Short Mood and Feelings Questionnaire to monitor outcomes for
treatment of depression; this instrument has separate forms that are completed by the patient
and the parent ( table 5 and table 6) [48-51]. The questionnaire is validated for both
children and adolescents, is brief and easy to interpret, and is in the public domain. A total score
≥8 on the patient form is considered clinically significant. The instrument lacks a question about
suicidal ideation; therefore, clinicians should ask about this. Clinicians may be familiar with
other available scales ( table 7), and it is reasonable to use them as an alternative to the Short
Mood and Feelings Questionnaire.
The most widely used and studied scale among adults is the self-report Patient Health
Questionnaire – Nine Item (PHQ-9). The PHQ-9 has also been used in adolescents [7]. In
addition, there is a modified form of the PHQ-9 specifically for adolescents (PHQ-9: Modified for
Teens) ( table 4) [8].
Although the Children’s Depression Rating Scale – Revised is used most widely in studies of
pediatric depression, this scale is typically not feasible for standard clinical care because it is
administered by clinicians.
Clinical outcomes — Clinical outcomes in depressive disorders are classified as follows

[10,52-54]:

● Response – Significant reduction (eg, ≥50 percent) of depressive symptoms during acute
treatment. Response often coincides with the onset of remission. We suggest monitoring
clinical improvement with standardized rating scales as well as measures of overall
psychosocial functioning ( table 7). (See "Using scales to monitor symptoms and treat
depression (measurement based care)".)
● Remission – Remission represents a period of time with minimal or no symptoms (eg,

depression rating scale scores and psychosocial functioning indices within normal limits, (
table 7)); the duration of this time period varies among different studies (eg, two to eight
consecutive months).
● Relapse – Recrudescence of the presenting depressive episode during remission.
● Recovery – An asymptomatic period with onset at the end of remission (there is no

established cutoff that separates the end of remission from the beginning of recovery).
● Recurrence – The emergence of unipolar major depression following recovery (a new

episode).
Additional information about the terms used to describe the clinical course of mood disorders is
discussed separately in the context of adults. (See "Unipolar depression in adults: Continuation
and maintenance treatment", section on 'Continuation and maintenance treatment'.)
ACUTE TREATMENT
The goal of acute treatment is remission of symptoms and return to baseline functioning [12].
However, remission often occurs in fewer than half of patients [55], whereas response (eg,
reduction of baseline symptoms ≥50 percent) occurs in up to 70 to 80 percent [56,57].
Remission or response typically occurs within 6 to 12 weeks, and treatment trials rarely last
more than 12 weeks.
Choice of therapy — The three treatment options that are generally used for pediatric
depression include:
● Pharmacotherapy (see "Pediatric unipolar depression and pharmacotherapy: Choosing a

medication" and "Pediatric unipolar depression and pharmacotherapy: General principles")
● Psychotherapy (see "Pediatric unipolar depression: Psychotherapy")
● Combination therapy (pharmacotherapy plus psychotherapy)
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Initial treatment — Choosing initial therapy for children and adolescents with acute
depression depends upon illness severity and duration; the presence of agitation, psychosis,
suicidal and homicidal ideation and behavior, as well as comorbidity (eg, anxiety and substance
use disorders); the patient’s age and functioning (eg, family conflict and academic problems);
the number of previous depressive episodes; and response to and adherence with prior
treatment [10]. Other factors to consider include adverse effects, availability of treatment
options, patient and family preference (including their assessment regarding the balance of
risks and benefits of therapy), clinician preference and familiarity with treatment options, and
cost.
For children and adolescents with moderate to severe (eg, suicidal behavior) unipolar major
depression, we suggest combination therapy with pharmacotherapy and psychotherapy as
initial treatment. Randomized trials suggest that combination therapy may provide a modest
advantage over pharmacotherapy alone and psychotherapy alone (see 'Combination therapy'
below), and the use of combination therapy is consistent with practice guidelines [10,58-60]. We
typically use selective serotonin reuptake inhibitors (SSRIs; eg, fluoxetine), and cognitive-
behavioral therapy (CBT), because they have been widely studied, especially in adolescents.
Reasonable alternatives include sertraline or escitalopram (for adolescents) and interpersonal
psychotherapy. (See "Pediatric unipolar depression and pharmacotherapy: Choosing a
medication", section on 'Efficacy' and "Pediatric unipolar depression: Psychotherapy", section on
'Studies of CBT'.)
Antidepressant monotherapy is often not considered sufficient in light of the adverse

psychosocial context in which depression frequently occurs. With few exceptions, the
environmental problems associated with unipolar major depression remain after the patient's
mood has stabilized. Combination treatment increases the chance of improving adaptive
behaviors and coping skills, family and peer relationships, and self-esteem, as well as reducing
the risk of relapse [10].
However, pharmacotherapy alone is a reasonable alternative for pediatric patients with

moderate to severe depression when psychotherapy is declined or is not available, provided
that the patient is regularly monitored (eg, every week, or every other week with a telephone
call in between, until improvement occurs) [56]. In addition, pharmacotherapy alone is indicated
for patients with severe symptoms (eg, psychotic features) that preclude psychotherapy, and
depression that does not respond to an adequate trial of psychotherapy alone [10].
Unipolar major depression with psychotic features requires treatment with an antidepressant
plus an antipsychotic. In addition, patients should be monitored closely for mania because the
risk of bipolar disorder is higher in patients with psychotic depression.

Choosing a medication and the general principles for administering pharmacotherapy are
discussed separately, as is the possible association between antidepressants and suicidal
thoughts or behaviors. (See "Pediatric unipolar depression and pharmacotherapy: Choosing a
medication" and "Pediatric unipolar depression and pharmacotherapy: General principles" and
"Effect of antidepressants on suicide risk in children and adolescents".)
For patients with mild episodes of major depression, we suggest psychotherapy alone (eg,
cognitive-behavioral therapy) as initial treatment [12]. (See "Pediatric unipolar depression:
Psychotherapy".) However, among youth who do not respond after six to eight weeks of
treatment, antidepressants should be added.
Treatment resistant depression — If the child or adolescent does not respond to treatment
using therapeutic doses within 6 to 12 weeks, we reevaluate the diagnosis of major depression,
especially to rule out bipolar disorder, and assess the patient for comorbid illnesses (eg,
substance use disorders), stressors (bullying, abuse, or family conflicts), side effects, or
nonadherence, which may impede improvement. If the diagnosis of major depression is
confirmed and potential factors for nonresponse are ruled out, our approach is as follows. For
children and adolescents with moderate to severe unipolar major depression who do not
respond to initial treatment with pharmacotherapy plus psychotherapy, we suggest switching
antidepressants from one SSRI to another and continuing psychotherapy, based upon clinical
experience.
For children and adolescents with moderate to severe unipolar major depression who do not
respond to initial treatment with pharmacotherapy alone, we suggest switching antidepressants
from one SSRI to another and adding CBT, rather than switching medications alone. However,
changing antidepressants and not adding psychotherapy is a reasonable alternative if
psychotherapy is declined or is not available.
Evidence for the efficacy of switching antidepressants and adding psychotherapy in depressed
adolescents who do not respond to antidepressant monotherapy includes a randomized trial
(the Treatment of Resistant Depression in Adolescents [TORDIA] study) that enrolled patients (n
= 334) with major depression who did not respond to eight weeks of treatment with an SSRI
[61]. Patients were assigned to one of four treatments: an alternative SSRI (citalopram,
fluoxetine, or paroxetine), the serotonin-norepinephrine reuptake inhibitor venlafaxine, an
alternative SSRI plus CBT, or venlafaxine plus CBT. Response (reduction of baseline symptoms
≥50 percent) occurred in more patients treated with a different medication (either a different
SSRI or venlafaxine) plus CBT, compared with patients who received a medication switch alone
(55 versus 41 percent). Although the response rates with both medication switch strategies

were similar, participants experienced fewer side effects when treated with an SSRI than when
treated with venlafaxine.
Additional information about treatment resistant depression is discussed in the context of

adults. (See "Unipolar depression in adults: Choosing treatment for resistant depression".)
Evidence of efficacy
Combination therapy — Pharmacotherapy plus psychotherapy appears to be efficacious for

pediatric depression. As an example, a 12 week randomized trial (Treatment for Adolescents
with Depression Study [TADS]) compared fluoxetine (10 to 40 mg per day) plus CBT (15 sessions,
each lasting 50 to 60 minutes) with pill placebo in 219 adolescents with unipolar major
depression [57]. Response (defined as much or very much improved) occurred in more patients
who received combination therapy than placebo (71 versus 35 percent).
In addition, short term treatment (eg, 12 weeks) with combination therapy may be superior to
pharmacotherapy alone and psychotherapy alone. However, the benefits of these three options
during longer-term (eg, 36 weeks) treatment generally appear to be comparable.
Compared with pharmacotherapy alone — For children and adolescents with depressive

disorders, combination therapy (pharmacotherapy plus psychotherapy) may provide a modest
advantage over pharmacotherapy alone in resolving depressive symptoms:
● A meta-analysis of four randomized trials (850 adolescents) compared pharmacotherapy

(SSRIs or venlafaxine) plus CBT with pharmacotherapy alone [62]. At the 12-week
assessment, improvement of depression and the incidence of suicidal ideation were each
comparable. However, functioning was better in patients who received combination
therapy.
● A meta-analysis of three trials compared SSRIs plus CBT with SSRIs alone in 419 adolescent
patients who were treated for 6 or 12 weeks, and found that there was a trend for
remission to occur in more patients who received combination therapy than SSRI
monotherapy (odds ratio 1.50, 95% CI 0.99-2.27) [63].
Combination therapy may also provide advantages over pharmacotherapy during treatment
that lasts longer than 12 weeks. As an example, a 36-week randomized trial compared
fluoxetine plus CBT with fluoxetine alone in 216 adolescents with unipolar major depression
[56]. Although response with combination therapy and fluoxetine monotherapy was
comparable, clinically significant suicidal ideation occurred in fewer patients who received
combination therapy than fluoxetine alone (3 versus 14 percent). Additional information about

antidepressants and risk of suicide is discussed separately. (See "Effect of antidepressants on

suicide risk in children and adolescents".)
Compared with psychotherapy alone — Combination therapy appears to be superior to

psychotherapy alone for short term treatment of adolescents with unipolar major depression. A
12-week randomized trial compared fluoxetine plus CBT with CBT alone in 218 adolescents with
unipolar major depression [55-57,64-71]. Remission occurred in more patients who received
combination therapy than CBT alone (37 versus 16 percent) [55]. In addition, improvement of
suicidal ideation was greater with fluoxetine plus CBT [57].
However, the advantage of combination therapy over psychotherapy alone during longer term
treatment appears to dissipate. As an example, a 36-week randomized trial compared fluoxetine
plus CBT with CBT alone in 218 adolescents with unipolar major depression [56]. Response was
comparable with combination therapy and CBT alone (86 and 81 percent of patients).
Pharmacotherapy — Medications that have been used as initial treatment for children and
adolescents with major depression include SSRIs, venlafaxine, and tricyclic antidepressants.
Randomized trials have shown that SSRIs (eg, fluoxetine), are superior to placebo; by contrast,
the benefits of venlafaxine are modest at best. Tricyclics are not used as initial treatment due to
limited benefits, as well as substantial problems with safety and adverse effects. The efficacy of
pharmacotherapy is discussed separately. (See "Pediatric unipolar depression and
pharmacotherapy: Choosing a medication".)
The use of antidepressants in children and adolescents is associated with a slightly increased
risk of suicidal thoughts and behaviors. (See "Effect of antidepressants on suicide risk in children
and adolescents".)
Compared with psychotherapy — For adolescents with unipolar major depression, short

term treatment with pharmacotherapy alone may be superior to psychotherapy alone. As an
example, a 12-week randomized trial compared fluoxetine with CBT in 220 adolescents with
unipolar major depression, and found that response (defined as much or very much improved)
occurred in more patients who received fluoxetine than CBT (61 versus 43 percent) [57].
However, the benefits of pharmacotherapy alone and psychotherapy alone during longer term
treatment appear to be similar. In a 36-week observational follow-up of an acute randomized
trial that compared fluoxetine alone with CBT alone in 220 adolescents with unipolar major
depression, response with fluoxetine and with CBT was identical (81 percent of patients) [56].
Psychotherapy — Randomized trials have shown that CBT and interpersonal psychotherapy

are better than control treatments for youth with major depression. However, other forms of

psychotherapy, such as dialectical behavior therapy, family therapy, psychodynamic

psychotherapy, supportive therapy, and other psychosocial interventions may also be beneficial
[72]. A qualitative review of 42 randomized trials found that treatment effects for psychotherapy
are often modest, and that fewer trials have been conducted in children than adolescents [73].
Psychotherapy may help patients and their families to [10,74]:
● Understand themselves and the nature of depression

● Change problematic behaviors
● Cope with depressive symptoms
● Manage relationships and life stressors associated with depression
● Improve social skills
● Increase self-confidence
● Prevent onset of depressive syndromes
● Adhere to treatment
The efficacy of psychotherapy for pediatric depression as well as an overview of psychotherapy

is discussed separately. (See "Pediatric unipolar depression: Psychotherapy" and "Overview of
psychotherapies".)
Electroconvulsive therapy — Observational studies suggest that electroconvulsive therapy

(ECT) can effectively treat adolescents with severe major depression that has not responded to
other treatments [75]. ECT is used with the caregivers' consent and adolescent's assent. In
addition, the need for ECT is typically based upon a consensus of multiple child and adolescent
psychiatrists, and government and hospital guidelines must be followed. Following a positive
response, continuation and maintenance ECT may be indicated [76]. The use of ECT for severe,
intractable depression is consistent with practice guidelines [77].
Additional information about ECT is discussed separately in the context of adults. (See
"Overview of electroconvulsive therapy (ECT) for adults" and "Unipolar major depression in
adults: Indications for and efficacy of electroconvulsive therapy (ECT)" and "Medical consultation
for electroconvulsive therapy" and "Technique for performing electroconvulsive therapy (ECT) in
adults".)
Adjunctive exercise — We suggest physical exercise as adjunctive treatment for patients

with unipolar major depression, based upon a systematic review of randomized trials that were
generally of low quality. The review included a meta-analysis of eight randomized trials that
compared exercise with control conditions in adolescents (n = 384) [78]. Exercise consisted of
some type of aerobic and/or strength training, and the control conditions consisted of
equivalent contact (attention) activities, usual care, or no treatment. The trials typically lasted 6

to 12 weeks, and included clinical samples as well as high school volunteers from the general
population. Self-reported depression was significantly lower with exercise than control
conditions, and the benefit was clinically moderate; however, heterogeneity across studies was
moderate to large. The review performed a second meta-analysis that included only the clinical
samples (four trials, n = 183 adolescents), and found a significant, clinically moderate effect
favoring exercise; heterogeneity was moderate.
Additional information about exercise is discussed separately, including the benefits of exercise
for depression in adults and the general health benefits and risks of exercise for adolescents
and adults. (See "Unipolar major depression in adults: Choosing initial treatment", section on
'Exercise' and "Physical activity and strength training in children and adolescents: An overview"
and "The benefits and risks of aerobic exercise".)
Comorbidity — Comorbid psychiatric disorders are common in pediatric depression and should

be treated [10]. Management is based upon the principle that clinicians initially treat the
disorder (ie, the depressive disorder or the comorbid disorder) that causes the greatest distress
or impairment. In addition, if a comorbid disorder (eg, substance use disorder or anorexia
nervosa) reduces the likelihood of recovery from depression, then the comorbidity should be
addressed first. Treating the comorbidity may improve the depressive symptoms (eg, initially
treating attention deficit hyperactivity disorder may improve the depressive syndrome). Also,
some comorbid disorders (eg, anxiety disorders) respond to the same treatments that are used
for depression.
Comorbidity may indicate the need for referral to mental health clinicians. (See 'Indications for
referral' above.)
Prognosis — Approximately 60 percent of children and adolescents with unipolar major

depression respond to initial treatment [10]. However, response is not the same as remission;
the threshold for response is relatively low, compared with remission. In addition, youth who
achieve a symptomatic response may still suffer functional impairment.
Baseline predictors of nonresponse include severe (intense) depressive symptoms such as

suicidal ideation with a plan and intent, suicidal or nonsuicidal self-injurious behavior, longer
duration of illness, hopelessness, poorer functioning, comorbid psychiatric disorders (eg,
anxiety disorders, substance use disorders, or obsessive-compulsive disorder), younger age,
history of abuse, disappointing life events, family psychopathology, and family conflicts [70,79-
86].
The long-term prognosis may not be related to the specific acute-phase treatment that is
administered. An observational study followed adolescents with unipolar major depression (n =

196) for up to five years after onset of acute, randomly assigned treatment with fluoxetine
alone, CBT alone, or fluoxetine plus CBT [80]. Almost all participants (96 percent) recovered, and
among those who recovered, relapse occurred in 47 percent. Neither recovery nor recurrence
(following recovery) was associated with any specific treatment. In addition, most patients
achieved developmental milestones (enrolled in college or obtained employment), and on
average, global functioning improved [87].
CONTINUATION TREATMENT
We suggest that all patients who respond to acute therapy receive continuation treatment to
prevent relapses [10]. Practice guidelines indicate that the acute phase psychosocial or
pharmacologic treatments that achieved remission should generally be used for continuation
therapy, unless the treatment is contraindicated (eg, intolerable drug side effects). However, for
patients who remit with pharmacotherapy alone, it can be useful to add psychotherapy to
prevent relapses (see 'Sequential treatment' below). During continuation treatment, patients are
typically seen every two to four weeks, depending upon their clinical status (including
comorbidities), functioning, support systems, stressors, motivation for treatment, and comorbid
psychiatric or general medical disorders [10,88].
Given the high rate of depressive relapses and recurrences in children and adolescents (40 to 60
percent), continuation therapy is recommended for all patients for at least 6 months after
complete remission of depressive symptoms (ie, return to baseline mood), and preferably 12
months [12,89]. Patients who had difficulty achieving remission, have a history of recurrent
depression, or present with ongoing risk factors (eg, comorbidity, suicidality, stressors, or family
history of depression) should receive continuation therapy for at least 12 months. However, if
the depressive episode was subsyndromal or mild, and occurred in the context of no prior
episodes of depression or major risk factors, an extended continuation phase is probably not
warranted.
Evidence for the efficacy of continuation treatment is discussed separately. (See "Pediatric
unipolar depression and pharmacotherapy: Choosing a medication", section on 'Continuation
and maintenance treatment' and "Pediatric unipolar depression: Psychotherapy", section on
'Maintenance phase and prevention'.)
Sequential treatment — Patients with unipolar major depression who respond to acute phase
pharmacotherapy may add psychotherapy (eg, CBT) for continuation treatment; this strategy is
called sequential treatment [90]. Adding psychotherapy may be indicated for poor adherence,
residual symptoms, or impaired functioning, as well as delaying or preventing relapse.

Evidence for the efficacy of sequential treatment includes randomized

continuation/maintenance trials:
● In one trial, 46 children and adolescents (age 11 to 18 years) with acute major depression
who responded (reduction of baseline symptoms ≥50 percent) to open label fluoxetine were
randomly assigned to six months of fluoxetine plus CBT (8 to 11 sessions that included a
family component) or fluoxetine alone [91]. Relapse occurred in fewer patients who
received pharmacotherapy plus CBT than pharmacotherapy alone (15 versus 37 percent).
However, global functioning was comparable for the two groups.
● A larger trial replicated the first study of fluoxetine plus CBT for preventing depressive
relapse. The larger trial included youths (age 8 to 17 years) with acute major depression
who responded to open label fluoxetine (n = 144) and were then randomly assigned to
fluoxetine plus CBT or fluoxetine alone for an additional six months [92,93]. CBT was
administered over 8 to 11 sessions, each generally lasting one hour; the first two sessions
included a family component. Patients were followed for up to 78 weeks after
randomization; during follow-up, time to remission of residual symptoms did not differ
between the two groups [93]. However, the estimated proportion of patients who relapsed
by week 78 was smaller with CBT plus fluoxetine than fluoxetine alone (36 versus 62
percent), and the mean time to relapse was longer with CBT plus fluoxetine by
approximately three months.
Additional information about sequential treatment of major depression is discussed separately

in the context of adults. (See "Unipolar depression in adults: Continuation and maintenance
treatment", section on 'Sequential treatment'.)
Discontinuing treatment — If the child or adolescent has had only a single, uncomplicated
episode of depression (eg, no suicidality or psychosis), discontinuation (rather than
maintenance treatment) is indicated once the continuation phase is complete. Discontinuing
treatment should be decided collaboratively with patients and families. To avoid withdrawal side
effects, the dose of most medicines needs to be slowly tapered (eg, approximately 25 to 50
percent per week) under the supervision of a physician.
Education about recurrence of depression is an important element of terminating treatment.

Patients and families should be taught to recognize and monitor prodromal signs of recurrence
( table 1), and have a plan in place to prevent full blown depressive episodes if prodromal
symptoms occur. In addition, the role of primary care clinicians in monitoring patients for
depressive symptoms cannot be overemphasized.

Additional information about discontinuing pharmacotherapy is discussed separately. (See

"Pediatric unipolar depression and pharmacotherapy: General principles", section on
'Discontinuing pharmacotherapy'.)
MAINTENANCE TREATMENT
After depressive symptoms have resolved and patients have remained euthymic for a period of
approximately 6 to 12 months (continuation phase), clinicians need to decide whether
maintenance treatment is indicated to prevent recurrences. We suggest maintenance treatment
for patients with risk factors associated with increased risk of recurrence, youth with recurrent
episodes of major depression (eg, three or more episodes), as well as patients whose acute
depressive episode preceding recovery was severe. Severity includes the intensity of symptoms,
duration of the episode, and the occurrence of psychosis, suicidality, and functional impairment.
Risk factors for recurrence are discussed separately. (See "Pediatric unipolar depression:
Epidemiology, clinical features, assessment, and diagnosis", section on 'Recurrence'.)
Maintenance therapy typically consists of treatments that achieved remission of the acute
episode and were used in continuation treatment (unless intolerable side effects intervene).
However, children and adolescents who recovered with pharmacotherapy can be offered add-on
psychotherapy to help them cope with the psychosocial sequelae of depression, and prevent
recurrence of depression and/or development or exacerbation of comorbid psychiatric
disorders [10,88].
Euthymic patients receiving maintenance treatment for depression are typically seen every one
to three months, depending upon clinical status. Patients who decompensate will need to be
seen more frequently, consistent with monitoring for acute treatment. (See "Pediatric unipolar
depression and pharmacotherapy: General principles", section on 'Frequency'.)
The duration of maintenance treatment lasts from one year to indefinitely. For children and
adolescents with two or three lifetime episodes of unipolar major depression, we recommend
maintenance treatment for one to three years, based upon studies in adults. We suggest even
longer maintenance therapy for patients with more than one episode accompanied by
psychosis (eg, delusions or hallucinations), moderate to severe suicidal ideation and/or behavior
(eg, suicidal ideation with a plan), moderate to severe functional impairment, or treatment
resistance.
The efficacy of maintenance pharmacotherapy is discussed separately. (See "Pediatric unipolar

depression and pharmacotherapy: Choosing a medication", section on 'Continuation and

maintenance treatment' and "Pediatric unipolar depression: Psychotherapy", section on

'Maintenance phase and prevention'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Depressive disorders".)
INFORMATION FOR PATIENTS AND FAMILIES
UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.”
The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Coping with high drug prices (The Basics)")
● Beyond the Basics topics (see "Patient education: Depression in children and adolescents
(Beyond the Basics)" and "Patient education: Depression treatment options for children and
adolescents (Beyond the Basics)" and "Patient education: Coping with high drug prices
(Beyond the Basics)")
Additional sources of information about unipolar major depression and treatment that is
intended for patients and families is discussed separately. (See 'Education and resources'
above.)
SUMMARY AND RECOMMENDATIONS
● Unipolar major depression (major depressive disorder) is characterized by a history of one

or more major depressive episodes ( table 1) in the absence of manic ( table 2) and

hypomanic ( table 3) episodes. (See 'Definition of unipolar major depression' above and
"Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)
● We generally do not administer psychotherapy to prevent depressive syndromes in children

and adolescents who are at risk of suffering a depressive disorder due to subsyndromal
symptoms, unless the youth has suicidal ideation or behavior, a comorbid psychiatric
disorder, functional impairment, has previously had a depressive syndrome, or requests
treatment. Nevertheless, it is reasonable to provide psychotherapy even in the absence of
these exceptions, or to monitor at-risk youth regularly. (See 'Prevention' above.)
● Depressed children and adolescents must be evaluated for suicide risk. (See "Suicidal
ideation and behavior in children and adolescents: Evaluation and management".)
● Indications for referral to a mental health specialist include current agitation, suicidal or
homicidal ideation or behavior, history of suicide attempt, inability of the family to monitor
the child’s or adolescent's safety, psychosis, bipolar depression, comorbidity, recurrent or
chronic depressive episodes, severe functional impairment, administration of
psychotherapy, and treatment resistant depression. (See 'Indications for referral' above.)
● Standard treatment options for pediatric depression include psychotherapy,

pharmacotherapy, or a combination of the two. (See 'Choice of therapy' above.)
● For children and adolescents with acute moderate to severe unipolar major depression, we
suggest pharmacotherapy plus psychotherapy as initial treatment rather than
pharmacotherapy alone or psychotherapy alone (Grade 2B). We typically choose a selective
serotonin reuptake inhibitor (eg, fluoxetine) plus cognitive-behavioral therapy (CBT).
However, antidepressant monotherapy is a reasonable alternative if psychotherapy is
declined or not available. In addition, psychotherapy alone is a reasonable alternative for
mild depressive disorders. The choice of therapy involves educating patients and families
about treatment options. Adjunctive exercise may also benefit patients. (See 'Initial
treatment' above and 'Evidence of efficacy' above and 'Education and resources' above and
"Pediatric unipolar depression and pharmacotherapy: Choosing a medication" and
"Pediatric unipolar depression: Psychotherapy".)
● For children and adolescents with moderate to severe unipolar major depression who do
not respond to initial treatment with pharmacotherapy plus psychotherapy, we suggest
switching antidepressants from one selective serotonin reuptake inhibitor to another and
continuing psychotherapy, rather than making other changes to the treatment regimen
(Grade 2C). For child and adolescent patients with moderate to severe unipolar major
depression who fail initial treatment with antidepressant monotherapy, we suggest

switching antidepressants and adding CBT, rather than switching antidepressants alone
(Grade 2B). However, switching antidepressants alone is a reasonable alternative if CBT is
declined or not available. (See 'Treatment resistant depression' above.)
● Pharmacotherapy may be associated with adverse events, including an increased risk of

suicidal thoughts or behaviors. (See "Pediatric unipolar depression and pharmacotherapy:
Choosing a medication" and "Effect of antidepressants on suicide risk in children and
adolescents".)
● For children and adolescents who are treated acutely with antidepressants and remit, we
recommend that the same regimen be continued for at least 6 to 12 months, rather than
discontinuing pharmacotherapy (Grade 1A). For patients treated acutely with
psychotherapy alone or psychotherapy plus pharmacotherapy, we typically continue the
same regimen for at least 6 to 12 months after remission. Further maintenance treatment
may be warranted based upon the patient's risk profile for recurrence. (See 'Continuation
treatment' above and 'Maintenance treatment' above and "Pediatric unipolar depression
and pharmacotherapy: Choosing a medication", section on 'Continuation and maintenance
treatment' and "Pediatric unipolar depression: Psychotherapy", section on 'Maintenance
phase and prevention'.)
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 1231 Version 42.0

GRAPHICS
DSM-5 diagnostic criteria for a major depressive episode
A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from
previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, hopeless)
or observations made by others (eg, appears tearful). (NOTE: In children and adolescents, can be irritable mood.)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by
either subjective account or observation)
3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or
decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.)
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of
restlessness or being slowed down)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick)
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their subjective account or as
observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt
or a specific plan for committing suicide
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another medical condition.
NOTE: Criteria A through C represent a major depressive episode.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a serious medical illness
or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss
noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a
significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgement based on
the individual's history and the cultural norms for the expression of distress in the context of loss.
D. The occurence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic
disorders.
E. There has never been a manic or hypomanic episode.
NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like epsidoes are substance-induced or are
attributable to the physiological effects of another medical condition.
Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American
Psychiatric Association. All Rights Reserved.
Graphic 89994 Version 12.0

DSM-5 diagnostic criteria for manic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently
increased activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if
hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if
the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
1) Inflated self-esteem or grandiosity.
2) Decreased need for sleep (eg, feels rested after only three hours of sleep).
3) More talkative than usual or pressure to keep talking.
4) Flight of ideas or subjective experience that thoughts are racing.
5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (ie, purposeless
non-goal-directed activity).
7) Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to
necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, other
treatment) or to another medical condition.
NOTE: A full manic episode that emerges during antidepressant treatment (eg, medication, electroconvulsive therapy) but
persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode
and, therefore, a bipolar I diagnosis.
NOTE: Criteria A through D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of
bipolar I disorder.

DSM-5 diagnostic criteria for hypomanic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently
increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if
the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a
significant degree:
1) Inflated self-esteem or grandiosity.
2) Decreased need for sleep (eg, feels rested after only three hours of sleep).
3) More talkative than usual or pressure to keep talking.
4) Flight of ideas or subjective experience that thoughts are racing.
5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
7) Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not
symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate
hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, or other
treatment).
NOTE: A full hypomanic episode that emerges during antidepressant treatment (eg, medication, electroconvulsive therapy)
but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic
episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or
agitation following antidepressant use) are not taken as sufficient for a diagnosis of a hypomanic episode, nor necessarily
indicative of a bipolar diathesis.
NOTE: Criteria A through F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not
required for the diagnosis of bipolar I disorder.

PHQ-9: Modified for teens
Name:
Clinician: Date:
Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each
symptom put an "X" in the box beneath the answer that best describes how you have been feeling.
More
Nearly
Not at Several than
every
all days half the
day
days
Score (0) (1) (2) (3)
1. Feeling down, depressed, irritable, or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Poor appetite, weight loss, or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself — or feeling that you are a failure, or that
you have let yourself or your family down?
7. Trouble concentrating on things like school work, reading, or

watching TV?
8. Moving or speaking so slowly that other people could have noticed?

Or the opposite — being so fidgety or restless that you were moving
around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in

some way?
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
0 to 4: No or minimal depression
5 to 9: Mild
10 to 14: Moderate
15 to 19: Moderately severe
≥20: Severe

In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
Yes
No
If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work,
take care of things at home, or get along with other people?
Not difficult at all

Somewhat difficult
Very difficult
Extremely difficult


Has there been a time in the past month when you have had serious thoughts about ending your life?
Yes
No
Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?
Yes
No
FOR OFFICE USE ONLY Score:
PHQ: Patient Health Questionnaire.
Modiﬁed from PHQ developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from
Pﬁzer Inc.

Short mood and feelings questionnaire - Self-report
This form is about how you might have been feeling or acting recently.
For each question, please check (✓) how you have been feeling or acting in the past two weeks.
If a sentence was not true about you, check NOT TRUE.

If a sentence was only sometimes true, check SOMETIMES.
If a sentence was true about you most of the time, check TRUE.
Score the MFQ as follows:

NOT TRUE = 0
SOMETIMES = 1
TRUE = 2
NOT SOME
To code, please use a checkmark (✓) for each statement. TRUE
TRUE TIMES
1. I felt miserable or unhappy.
2. I didn't enjoy anything at all.
3. I felt so tired I just sat around and did nothing.
4. I was very restless.
5. I felt I was no good anymore.
6. I cried a lot.
7. I found it hard to think properly or concentrate.
8. I hated myself.
9. I was a bad person.
10. I felt lonely.
11. I thought nobody really loved me.
12. I thought I could never be as good as other kids.
13. I did everything wrong.
Copyright © 1987 Adrian Angold and Elizabeth J. Costello; Developmental Epidemiology Program, Duke University. Reproduced with
permission.

Short mood and feelings questionnaire - Parent report
This form is about how your child might have been feeling or acting recently.
For each question, please check (✓) how s/he has been feeling or acting in the past two weeks.
If a sentence was not true about your child, check NOT TRUE.
If a sentence was only sometimes true, check SOMETIMES.
If a sentence was true about your child most of the time, check TRUE.
Score the MFQ as follows:

NOT TRUE = 0
SOMETIMES = 1
TRUE = 2
NOT SOME
To code, please use a checkmark (✓) for each statement. TRUE
TRUE TIMES
1. S/he felt miserable or unhappy.
2. S/he didn't enjoy anything at all.
3. S/he felt so tired that s/he just sat around and did nothing.
4. S/he was very restless.
5. S/he felt s/he was no good anymore.
6. S/he cried a lot.
7. S/he found it hard to think properly or concentrate.
8. S/he hated him/herself.
9. S/he felt s/he was a bad person.
10. S/he felt lonely.
11. S/he thought nobody really loved him/her.
12. S/he thought s/he could never be as good as other kids.
13. S/he felt s/he did everything wrong.
Copyright © 1987 Adrian Angold and Elizabeth J. Costello; Developmental Epidemiology Program, Duke University. Reproduced with
permission.

Measures used to monitor clinical improvement of depressive symptoms and global

functioning in depressed children and adolescents
Depressive symptoms
Children's Depression Rating Scale - Revised
Revised (CDRS-R) Clinician rating scale based on a semi-structured interview with child/adolescent patient and parent
informant. The CDRS is the most widely used and highly regarded clinician scale for monitoring response to treatment in
children and adolescents. Modeled after the adult Hamilton Rating Scale for Depression, the CDRS was developed to assess
current severity of depression in children ages 6 to 12 years and is often used for adolescents as well. The revision of the
CDRS examines 17 symptom areas (eg, depressed feelings, sleep disturbance, social withdrawal, etc) and can be
administered in 15 to 20 minutes. The CDRS-R can be purchased at www.proedinc.com.
Patient Health Questionnaire - Nine Item (PHQ-9): Modified for Teens
Self-report measure that consists of the nine criteria that are used by the Diagnostic and Statistical Manual of Mental
Disorder, Fifth Edition (DSM-5), to diagnose major depression. The PHQ-9: Modified for Teens is derived from the PHQ-9,
which is the most widely used instrument for measurement based care in adults. The PHQ-9: Modified for Teens requires
approximately five minutes to complete and is in the public domain.
Short Mood and Feelings Questionnaire
Self-report measure that has a separate form that is completed by the child or adolescent and by the parent. Each form
contains 13 items and requires approximately five minutes to complete. The Short Mood and Feelings Questionnaire is in the
public domain and is based upon the longer Mood and Feelings Questionnaire.
Revised Hamilton Rating Scale for Depression (RHRSD)
Clinician rating for adult depression that is used often with older adolescents. The revision retains the original Hamilton
items, adds items, and includes a self-report version. The RHRSD takes 5 to 10 minutes to administer and is available for
purchase at www.wpspublish.com.
Children's Depression Inventory-2 (CDI-2)
Self report measure designed for assessment of depressive symptoms in children/adolescents ages 7 to 17. CDI-2 is a
revision of the CDI. Revision includes new items, revised scales, and updated norms. Assesses current severity of depressive
symptoms. Parent and teacher versions of CDI are available. A self rating short form takes about 5 to 10 minutes to
complete. All versions are available through www.mhs.com.
Beck Depression Inventory II (BDI-II)
Widely used self-report rating scale designed for use with adults and adolescents older than 13 years of age. It takes 5 to 10
minutes to complete. It is available for purchase at www.harcourtassessment.com.
Reynolds Adolescent Depression Scale, Second Edition (RADS-2)
Self-report measure designed for assessment of depressive symptoms in adolescents 11 to 20 years of age. It may be
administered in 5 to 10 minutes and is available at www.parinc.com or www.wpspublish.com.
Center for Epidemiological Studies Depression Scale Modified for Children (CES-DC)
Adapted version of the adult Center for Epidemiological Studies Depression Scale. It is a 20-item scale designed for use with
children/adolescents ages 6 to 17. The CES-DC takes approximately five minutes to complete and is available in the public
domain. Scores greater than 15 suggest significant levels of depressive symptoms. It can be found at
www.brightfutures.org/mentalhealth/pdf/tools.html (scroll to "Bridges" section and then will find under a Mood Disorders
link).
Clinical Global Impression (CGI) Scale
The CGI is a three-item clinician rating scale used to assess treatment response (typically in research settings, often as an
adjunct outcome measure). It is an unanchored measure (ie, there is no specific assessment). The ratings refer to the global
impression of the patient and require substantial clinical experience with the syndrome under assessment. The three items
are Severity of Illness, Global Improvement, and an Efficacy Index. Most use only the severity and improvement indices.
The Severity of Illness item (CGI-S) requires a seasoned clinician to rate the severity of the patient's illness on a 7-point
scale from 1 ("normal," not ill) to 7 (extremely ill).
The Global Improvement item (CGI-I) requires a seasoned clinician (who has knowledge of the patient's history) to rate
how much the patient's illness has improved or worsened relative to baseline status. The patient's illness is compared to
baseline rated on a 7-point scale from 1 (very much improved) to 7 (very much worse).
Courtesy of Liza Bonin, PhD.

Overview of Prevention and Treatment For Pediatric Depression - UpToDate

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11/30/2020 Overview of prevention and treatment for pediatric depression - UpToDate

Official reprint from UpToDate®

Overview of prevention and treatment for pediatric

This topic provides an overview of treating pediatric depression. Pharmacotherapy and

● (See "Pediatric unipolar depression and pharmacotherapy: General principles".)

● (See "Pediatric unipolar depression and pharmacotherapy: Choosing a medication".)

● (See "Pediatric unipolar depression: Psychotherapy".)

● (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and

https://www-uptodate-com.upmx.idm.oclc.org/contents/overview-of-prevention-and-treatment-for-pediatric-depression/print?sectionName=ACUTE TREATMENT… 1/32

DEFINITION OF UNIPOLAR MAJOR DEPRESSION

Mild to moderate major depression is characterized by clinical features such as:

● No psychotic features (eg, delusions or hallucinations).

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Administering psychotherapy to children and adolescents in targeted populations can prevent

Targeted (selected) populations — Targeted treatment with psychotherapy to prevent either

Evidence regarding the use of psychotherapy to prevent depressive disorders includes a

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Universal (unselected) populations — We do not suggest universal prevention for depressive

GENERAL PRINCIPLES OF TREATING YOUTH WITH MAJOR DEPRESSION

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Education and resources — An important component of treating depression in youths is

Education addresses the:

● Use of pharmacotherapy. (See "Pediatric unipolar depression and pharmacotherapy:

● Use of psychotherapy. (See "Pediatric unipolar depression: Psychotherapy", section on

● Role of parents and teachers in treatment.

Additional information for parents and adolescents about depression in adolescents is

https://www-uptodate-com.upmx.idm.oclc.org/contents/overview-of-prevention-and-treatment-for-pediatric-depression/print?sectionName=ACUTE TREATMENT… 5/32

● American Academy of Child and Adolescent Psychiatry (www.aacap.org)

● United States Food and Drug Administration

● The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit

● American Psychiatric Association (www.psych.org)

● American Psychological Association (www.apa.org)

● National Alliance for the Mentally Ill (www.nami.org)

● National Institute of Mental Health

● Mental Health America (http://www.mentalhealthamerica.net)

● Resources for integrated health care (see 'Collaborative care' below)

Collaborative care — Collaborative (integrated) care involves pediatric primary care clinicians

assessment and diagnosis of pediatric depression, information on various treatment options,

Resources for integrated health care include the following:

● The Massachusetts Child Psychiatry Access Project (MCPAP, www.mcpap.org) provides

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Indications for referral — Although pediatric major depression is often treated successfully by

● Uncertainty about the diagnosis of major depression

● Discomfort managing pediatric depression

● Current agitation, suicidal or homicidal behavior, history of suicide attempt, or inability of

● Recurrent or chronic (eg, ≥2 years) depression

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● Administration of psychotherapy (eg, cognitive-behavioral therapy or interpersonal therapy)

Monitoring — We suggest that clinicians (eg, pediatricians, psychiatrists, or psychologists) who

Clinical outcomes — Clinical outcomes in depressive disorders are classified as follows

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● Remission – Remission represents a period of time with minimal or no symptoms (eg,

● Relapse – Recrudescence of the presenting depressive episode during remission.

● Recovery – An asymptomatic period with onset at the end of remission (there is no

● Recurrence – The emergence of unipolar major depression following recovery (a new

● Pharmacotherapy (see "Pediatric unipolar depression and pharmacotherapy: Choosing a

● Psychotherapy (see "Pediatric unipolar depression: Psychotherapy")

● Combination therapy (pharmacotherapy plus psychotherapy)