Major Depressive Disorder (MDD) is defined by the experience of a depressed mood or anhedonia (a loss of interest or pleasure) persisting nearly all day, every day for at least two weeks, which distinguishes it from an occasional sad mood or lack of interest that lasts for a few hours or days. (1) Based on the severity of symptoms, functional impairment, and level of patient distress, MDD can be characterized as mild, moderate, or severe. Major depressive disorder is one of the most common psychiatric disorders of childhood and adolescence, but because of symptom variation from the adult criteria, it is often unrecognized and untreated. (6)
This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of major depressive disorder in children and adolescents.
Diagnostic Considerations for MDD in Children and Adolescents
Is your patient experiencing five or more of the following, most days? One of the 5 must be depressed mood or anhedonia for at least 2 weeks
- Depressed mood - mood can be described as irritable
- Loss of interest or pleasure in all, or almost all, things they previously enjoyed (anhedonia)
- Loss of appetite
- Difficulty falling or staying asleep, or excessive sleep
- Loss of energy
- Psychomotor agitation or retardation
- Feeling guilty, worthlessness, hopelessness
- Trouble concentrating
- Suicidal ideation
Have the above symptoms negatively impacted the patient's ability to function in important areas of life, such as in relationships, at work, at school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc)?
It’s important to note, that the above symptoms and experiences may also be attributable to an alternative disorder (such as persistent depressive disorder, disruptive mood dysregulation disorder, or bipolar disorder), a neurological cause, or due to the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining if MDD is the clinically indicated diagnosis.
For complete diagnostic criteria of Major Depressive Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787.
| When documenting care, be sure to include the specific symptoms of MDD experienced by the patient and how they fit within the DSM-5 diagnostic criteria. |
Symptom Screening and Monitoring
The Patient Health Questionnaire - 9 A item (PHQ-9 A) (11) is a brief validated, patient self-report screening tool used to assess the frequency and severity of depressive symptoms in patients 11 - 17 years old. If the PHQ-9 A is not available, the psychiatry provider may use the PHQ-9 version. Routine use of this measure is foundational to providing effective care for individuals who experience depression, as it supports accurate diagnoses, identification of treatment plan goals based on symptom severity, and can guide effective clinical interventions. Please utilize this tool during all new intake visits to establish a baseline measurement and in your follow-up visits as a way to track progress.
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It may be helpful to draw labs to help rule out any medical causes of depression including thyroid issues or anemia. If the psychiatric provider feels this is necessary based on presentation and history, you can order this through AMD. If you have a Kaiser patient, please let psych support know what labs you wish to order for the patient. It is important to gather collateral when treating children and adolescents. Be sure to document the patient’s concerns as well as any concerns that the legal guardian has as well. |
| It is important for the psychiatric provider to maintain a confidential relationship with the child and/or adolescent while developing collaborative relationships with legal guardians. There is only one exception: the psychiatric provider should break confidentiality if the patient is having active SI and is a threat to themselves and/or others. |
Evidence-Based Approaches to Treatment
The American Academy of Child and Adolescent Psychiatry (AACAP) has determined that it is important for patients to have an acute (6-12 weeks), continuation phase (4-9 months) of treatment, and sometimes a maintenance phase. For patients with mild depressive symptoms, the recommendation is to utilize psychoeducation, family and school involvement, as well as psychotherapy. For patients who experience moderate to severe depressive symptoms, the use of antidepressants in addition to psychotherapy has demonstrated efficacy. (11)
Psychotherapy
Psychiatric providers are encouraged to become familiar with each of the different evidence-based approaches, as well as engage in shared decision-making with the patient to determine which intervention is right for each clinical situation.
- Cognitive-behavioral therapy (CBT) is the most studied psychotherapy for depression and has the largest weight of evidence for its efficacy.
- Interpersonal psychotherapy (IPT)
- Problem-solving therapy (PST)
Meta-analyses that compare the effectiveness of CBT, IPT, and PST indicate no large differences in effectiveness between these treatments.
Behavioral activation is an effective structured treatment approach that aims to increase enjoyable activities and adaptive behaviors while decreasing behaviors that increase the risk of depression or maintain it. Activities can fall into different categories, including (11):
- Pleasure activities: These activities increase joy or delight, such as hobbies, interests, play, socializing, or sensory experiences. Examples include relaxing activities like baths or massages, nature walks, mindful cooking, sports, games, creative projects, and learning or practicing a skill.
- Mastery activities: These activities involve developing skills and accomplishing things, such as work or sports.
- Emotional activities: These activities aim to experience or accept feelings.
- Mental activities: These activities challenge you to think about new ideas.
- Physical activities: These activities improve your physical health.
- Social activities: These activities connect you with others.
- Spiritual activities: These activities show your values.
Medication
The class of antidepressants includes SSRIs are recommended as “first-line” medications for use in the treatment of depression for children and adolescents. These medications regulate the neurotransmitters serotonin, norepinephrine, and dopamine, which are involved in brain functions related to mood and behavior. There has been newer research that shows that these medications increase the density of synapses which is why they can take weeks to be effective. Here is a brief table of FDA-approved medications in children and adolescents
In children/adolescents, there are two approved for MDD:
SSRIs
- Fluoxetine (Prozac) - approved for children 8+
- Escitalopram (Lexapro) - approved for adolescents 12+
In children/adolescents, we may use other SSRIs or SNRIs to help treat depressive symptoms. However, these are not FDA-approved for MDD in children/adolescents so we must make the patient and legal guardian aware of off-label prescribing. The research is limited to SSRIs and children/adolescents with various anxiety disorders; however, many of these medications are safe and effective according to numerous studies. Some examples that could be used include but are not limited to:
SSRIs
- Sertraline (Zoloft) - approved for OCD in children 6+
SNRIs:
- Duloxetine (Cymbalta) - approved in GAD 7+
If the patient is not responding to pharmacotherapy plus psychotherapy, please consider the following
- Misdiagnosis
- Untreated comorbid disorder (i.e. anxiety, substance use, hypothyroidism, etc)
- Compliance with medications
- Inadequate length of treatment or dosage
- Medication side effects
- Exposure to severe life events (i.e. sexual assault, family conflicts)
There are several recommendations for adults for treatment-resistant depression that may apply to adolescents:
- Switching to a different medication in the same drug class
- Augmenting with atypical antipsychotics - this would be considered off-label (Abilify)
- Lithium has shown some improvement in studies with adolescents - this would be considered off-label
There have been some studies using ECT in adolescents showing they may respond but more research is needed.
**Benzodiazepines (such as diazepam and clonazepam) are generally not recommended for the treatment of depression due to their high potential for dependence as well as their limited long-term effectiveness.
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Remember to start low and go slow with medications in children/adolescents. If you are going to use a medication that is considered ‘off label’ for children/adolescents make sure to document that this was discussed with a legal guardian and that treatment was consented to. |
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It is important to discuss/document the SSRI FDA black box warning for all patients aged 24 years or younger. The Food and Drug Administration (FDA) requires a "black box" warning that antidepressant medications may sometimes increase suicidal ideation in children, adolescents, and young adults (aged 18–24) during initial treatment (generally the first 1–2 months) and at times of dose changes. Families and caregivers of patients being treated with antidepressants should be alerted about the need to monitor patients daily for the emergence of agitation, irritability, and unusual changes in behavior. Note: The overall rate of suicidal ideation is lower in patients treated with antidepressants compared to those given placebo, and this should be considered when discussing the risks and benefits of antidepressant therapy. |
Assessing Risk and Higher Level of Care Needs
The risk of suicide in individuals with major depression is about 20 times that of the general population. (5) Research has shown that feelings of hopelessness, worthlessness, delusionally depressive thoughts, anxiety, and sleep disturbances, directly and indirectly contribute to an increase in the risk of suicide attempts. Adolescents are shown to have high rates of suicide due to impulsivity.
Particularly for patients who respond affirmatively to thoughts of suicide or self-harm on the PHQ-9 (Question #9) or any item on the C-SSRS (Columbia Suicide Severity Rating Scale) Screener, it is imperative that psychiatric providers engage in (and document) thorough risk assessment, completion of a safety plan and referral for additional services (such as inpatient care, IOP, PHP, Group therapy) if clinically indicated.
What if my patient has passive SI and/or chronic SI?
There are times when patients will endorse passive SI and/or chronic SI. It is important to complete the C-SSRS to determine the risk level of the patient, if the patient is not a high risk with active SI, then we can engage the patient in the following ways
- The first step for a patient who is expressing passive and/or chronic SI is to identify protective factors and future orientation.
- Next, we should complete a safety plan in collaboration with the patient. We use the Stanley-Brown Safety Plan that can be found in the AMD note template. It is important to do this with the patient to engage them in their treatment.
- It is important to document that a safety plan was completed and that the patient agrees to safety
- Sometimes patients may struggle to answer questions on the safety plan including internal coping skills, people they can ask for help when/if a crisis occurs, and/or places that provide distraction.
- We can offer coping skills that may be of use i.e. deep breathing, coloring, music, grounding techniques, etc. See what the patient likes to do to help ease their emotions.
- Sometimes patients may not have people but have pets that they can go to when in a crisis
- It is important to assess SI at every follow-up visit as well as going over the safety plan to make adjustments, if needed.
- It may be that the patient would benefit from increased therapy sessions. We can collaborate with the therapists by asking the psych support team for their emails.
- We may want to see the patients more frequently than every month i.e. every 2 weeks until SI is stable.
- It is important to ask if the patient is using substances, if they are, it is important to talk about decreasing substance usage as this can increase impulsivity.
- If the patient does not have resources or support, it is helpful to connect them Resources for People who Think About Suicide (and their supporters) | NAMI Massachusetts.
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Rula’s team of care coordinators is available to support your patient in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC). Care coordination will assist in helping the patient get into IOP, PHP, Group therapy, etc. However, if your patient is an acute risk to self or others i.e. active SI with plan, intent, or means then please follow this protocol here. Please reach out to the RNs and Lead NPs to help you in this situation for additional support. |
Cultural Considerations
The expression of depressive symptoms is often influenced by cultural contexts, including perceptions of illness and symptoms (including their causes), social pressures and stigma, gender, and racial identification, what life experiences are considered typical in a particular cultural environment as well as how one is expected to respond or cope with those stimuli. In some cultures, depressive symptoms might not be expressed in words at all, but in the form of physical symptoms, such as headaches, backaches, or stomach discomfort. Some clients may feel their symptoms are better explained through a lens of religious or spiritual beliefs and values. (6) As a result, it is important to always consider the social and cultural contexts of a client's treatment needs as part of the diagnostic process.
“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.”(7)
Resources:
- Major depressive disorder in children and adolescents
- 988 Suicide & Crisis Lifeline
- Behavioral Activation in Depression
- Adult & Adolescent Depression Screening, Diagnosis, and Treatment Guideline
- AACAP: Depression – Parents' Medication Guide
- Suicide in Children and Teens
References
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Anxiety & Depression Association of America. https://adaa.org/resources-professionals/practice-guidelines-mdd
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American College of Physicians. https://www.acpjournals.org/doi/10.7326/M22-2056
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American Psychiatry Association https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
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American Psychological Association. https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
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American Academy of Suicidology. https://www.cga.ct.gov/asaferconnecticut/tmy/0129/Some%20Facts%20About%20Suicide%20and%20Depression%20-%20Article.pdf
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Mental Health Clinician. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213890/pdf/i2168-9709-8-6-275.pdf
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Anxiety and Depression Association of America https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/influences-cultural-differences-diagnosis-and
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Kaiser Permanente https://wa.kaiserpermanente.org/static/pdf/public/guidelines/depression.pdf
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National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/
11. American Academy of Child and Adolescent Psychiatry (AACAP)
https://www.jaacap.org/article/S0890-8567(22)01852-4/abstract
Updated