Effective management of depression and other mood disorders in children may involve both pharmacotherapy with behavioral recommendations and psychotherapy, according to Stephen P. Whiteside, Ph.D., and Dr. John Huxsahl of the Mayo Clinic in Rochester Minn.

In a presentation at the American Academy of Pediatrics annual meeting in Washington, they reviewed the differences between various mood disorders because accurate diagnosis is a key component to management.

A major depressive episode is among the more common mood disorders among children, but others include disruptive mood dysregulation disorder, persistent depressive disorder, and bipolar I disorder. Because most pediatricians have just 15 minutes or so with patients, Dr. Whiteside and Dr. Huxsahl recommended using screening questionnaires to identify children at risk for a mood disorder. Trying to determine why a child is experiencing these symptoms or feelings can help clinicians determine whether this is a chronic issue or a situational one. Asking about other concerns, such as anxiety or use of substances, also can help with diagnosis.

Depressive episodes

Occurring among approximately 2% of children and 4%-8% of adolescents, a major depressive episode lasts a median of 8 months, but has a very high rate of recurrence: 20%-60% at 1 or 2 years after remission and 70% at 5 years after remission. In a significant proportion of children – about 20%-40% – a major depressive episode forecasts bipolar disorder.

In fact, having a parent with a mood disorder doubles to quadruples a child’s risk of major depressive episodes, and the disorder frequently occurs with anxiety, estimated in approximately 61%-65% of children with a major depressive episode. An episode generally appears to result from a combination of genetic factors and environmental ones, including abuse, neglect, family conflict, childhood adversity, losses, and comorbid disorders.

More heterogeneous than in adults, major depressive episodes in children look different based on a child’s age, according to Dr. Whiteside and Dr. Huxsahl:

• Birth to age 2 years. Symptoms include whining, decreased growth, lack of responsiveness, disrupted sleep, and excessive fears.

• Ages 3-5 years. Symptoms include anxiety, somatic symptoms, tantrums, sadness, weight gain, tiredness/sleepiness, suicidal ideation, anger or irritability, apathy, illness, and social withdrawal

• Ages 6-12 years. Symptoms include sadness, an inability to experience pleasure, decreased energy, low self-esteem, irritability, and suicidal ideation.

• Ages 12-18 years. Symptoms include a volatile mood, rage, acting out, self-consciousness, withdrawal, suicidal ideation, and overeating and/or oversleeping.

Other mood disorders

Disruptive mood dysregulation disorder (DMDD) involves much more acting out at a younger age than major depressive episodes. In children with DMDD, outbursts greatly exceed what would be expected in response to a situation, whether in terms of how long the tantrums last or how intense they are. These outbursts also are unexpected developmentally, with an onset before age 10 years, although the disorder should not be diagnosed earlier than age 6 years. Diagnostic criteria also require that the outbursts occur at least three times weekly, on average, for at least 12 months in at least two settings with a persistently angry or irritable mood between outbursts.

One way to support a diagnosis of DMDD is to rule out what it’s not. DMDD can exist with comorbidities of major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and substance use disorders, and it’s most likely to grow into depression or anxiety. It cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, and it does not develop into bipolar disorder.

Persistent depressive disorder resembles MDD, with either a depressed mood lasting at least 2 years or an irritable mood lasting at least 1 year plus at least two of the following symptoms: poor appetite or overeating; insomnia or hypersomnia; low energy or fatigue; poor concretion or difficulty making decisions; feelings of hopelessness; and low self-esteem.

Bipolar disorder

“The most important part of managing bipolar I is episodes, episodes, episodes,” Dr. Whiteside said. Alternating with either hypomanic or major depressive episodes are manic episodes, in which a child experiences an abnormal “high,” a period of at least a week of extremely high energy nearly all day, every day, with a “persistently elevated, expansive, or irritable mood.”

For an episode to be considered manic, however, at least three of the following seven other symptoms must be present, and deviate from the patient’s otherwise normal behavior: grandiosity or an especially inflated sense of self-esteem; a decreased need for sleep (not just that the patient doesn’t sleep but doesn’t actually seem to need to); extreme talkativeness or use of pressured speech; a feeling of having racing thoughts or ideas flying about; a tendency to be easily distracted or unfocused; an increase in activities aimed at accomplishing certain goals (in any sphere, for example, school, work, social, or sexual); and risky behaviors with potentially severe, long-term consequences, such as more frequent sexual behavior or shopping sprees.

Dr. Whiteside compared bipolar disorder to ADHD to help clinicians appreciate how to best understand it. Key differences with ADHD are an earlier age of onset, a more consistent presence of symptoms without episodes, a need for sleep despite possible insomnia, and only situational depression. In a 1998 study, a comparison of bipolar I and ADHD revealed that 89% of bipolar children had an elevated mood, compared with just 14% of those with ADHD. A similar gulf existed with grandiose thoughts, occurring in 86% of children with bipolar disorder and 5% of those with ADHD. Likewise, a much greater proportion of children with bipolar disorder experienced “flights of ideas,” decreased sleep, or hypersexuality, compared with these symptoms in children with ADHD.

Treating depression: Behavioral interventions

Psychopharmacology can be beneficial, but it works best when combined with behavioral interventions and simply explaining the disorder, said Dr. Whiteside. “There’s a lot of evidence that exercise can be a powerful treatment with depression,” he said. “Education is especially important since one of the four features of depression is a sense of hopelessness and belief that nothing is going to [get] better, so for them to know there are steps they can take is a very powerful intervention itself.”

The most effective intervention, however, is cognitive-behavioral therapy, with an 81% success rate 1 year out and a 98% success rate 2 years out. After the initial intervention, however, the numbers are more modest, with 67% of children no longer meeting major depressive disorder criteria when undergoing cognitive-behavioral therapy, compared with 48% in the waiting-list control group.

An important aspect to education starts with developing an alliance with a family so that the clinician can explain the condition and its treatment, build trust, and instill hope. In doing so, both parents’ and children’s expectations can be adjusted so that children feel less guilty and parents respond less negatively to their children.

Treatment with medication

Although only fluoxetine and escitalopram have Food and Drug Administration approval for MDD, Dr. Huxsahl recommended starting kids with mixed anxiety and depression on fluoxetine, fluvoxamine, or sertraline, and suggested clinicians not shy away from the target doses recommended for each drug. After 2-4 months of acute treatment, clinicians also should help families understand that continuing the treatment for at least 4-9 months and then potentially taking a maintenance dose for up to 3 years may be recommended.

“I would encourage you to educate the parents, and especially the teenagers, that they need to take the medication beyond the time that they are depressed,” he explained. Initially, however, start with a low dose and then increase it within 4 weeks if no response occurs. After 8 weeks, switch agents if no response has occurred, a process that requires monthly visits for the first 3-6 months of treatment.

Another question families and clinicians face is when to taper off medication when moving to a maintenance dose or working toward no longer taking the medication.

“In at least one study where they randomized kids to tapering during the school year or in the summer, the findings showed that the kids actually did better in the summer,” said Dr. Huxsahl. But follow-up is important during cessation because during the first 2-3 months is when there is the greatest risk for relapse or recurrence.

Dr. Whiteside and Dr. Huxsahl said they had no relevant financial disclosures.