Pediatric Considerations for Depression
There is limited information concerning the incidence of depression in healthy children. One study of children seen in a general practice showed that 38% had problems that required major intervention by a psychiatrist. Another study of children aged 7 to 12 years showed a 1.9% incidence of depression. If applied to the general population of the United States, these results show that 40,000 12-year-olds are depressed. Teachers have estimated that as many as 10% to 15% of their students are depressed. The Joint Commission on Mental Health of Children states that 1.4 million children younger than 18 years need immediate help for disorders such as depression; only one-third of these children receive help for their disorder.
Most children cope with the emotional upheaval related to cancer and demonstrate not only evidence of adaptation but positive psychosocial growth and development. A minority of children, however, develops psychological problems including depression, anxiety, sleep disturbances, difficulties in interpersonal relationships, and noncompliance with treatment. These children require referral and intervention by a mental health specialist.
In one of the first studies of depression in childhood cancer, 114 children and adolescents were studied, and 59% were found to have mild psychiatric problems. A study of 17 adolescent and 21 pediatric oncology patients, all of whom were administered a self-report psychosocial life events inventory, showed that the adolescent samples had a mean level of depressive symptoms similar to that of the general population. The pediatric oncology sample demonstrated significantly lower depressive symptoms than the general population.[Level of evidence: II] Forty-one adolescent survivors of childhood cancer were assessed using questionnaires and interviews to determine the psychosocial status of the survivors; most survivors were functioning well, and depression was rare. A study of long-term cancer survivors and their mothers, comparing the survivors with a group of 92 healthy children, showed that the majority of former patients were functioning within normal limits. Not surprisingly, children with severe late effects had more depressive symptoms.[Level of evidence: II] One researcher looked at the characteristics of psychiatric consultations in a pediatric cancer center and found that adjustment disorder was the chief psychosocial diagnosis. This finding is similar to results obtained from adult cancer patients. This study also found that anxiety reactions were more common in the younger pediatric patients and depressive disorders were more common in older patients. In a study conducted in 1988 with a sample of 30 adolescent cancer patients, the rate of major depression was not greater than the rate for the population at large.[Level of evidence: II] One review reported a 17% incidence of depression using the Diagnostic and Statistical Manual for Mental Disorders, 3rd Edition criteria.
Most cancer survivors demonstrate general resiliency and successful psychological adjustment to the disease and its treatment. Despite evidence for successful adaptation, most studies document psychological difficulties in a significant subset of cancer survivors.
Assessment and Diagnosis of Pediatric Depression
The term depression refers to a symptom, a syndrome, a set of psychological responses, or to an illness. Duration and intensity of the behavioral manifestation (e.g., sadness) differentiates the symptoms from the disorder. For example, a sad affect can be a child's response to trauma and is usually of short duration; however, a depressive illness is characterized by long duration, and is associated with insomnia, irritability, changes in eating habits, and severe impairment of the child's scholastic and social adjustment. Depression should be considered whenever any behavior problem persists. Depression does not refer to transitory moments of sadness, but rather to a disorder that affects development and interferes with realization of the child's innate potential.
Some manifestations of depression in a school-aged child include anorexia, lethargy, sad affect, aggression, weeping, hyperactivity, somatization, fear of death, frustration, feelings of sadness or hopelessness, self criticism, frequent day dreaming, low self-esteem, school refusal, learning problems, slow movements, vacillating hostility towards parents and teachers, and loss of interest in previously pleasurable activities. Differentiating these symptoms from behavioral responses to normal developmental stages is important.
Assessment of depression includes determination of the child's family situation, level of emotional maturity, ability to cope with illness and treatment, age, state of development, previous experience with illness, and personal ego strength.
A comprehensive assessment for childhood depression is the basis for accurate diagnosis and treatment. Evaluation of the child and family situation focuses on the pediatric health history, behaviors observed by the practitioner or reported by others (e.g., parents, teachers), interviews with the child, and judicial use of tests such as the Beck Depression Inventory or the Child Behavior Checklist.
In discussing the diagnosis of childhood depression, experts stress the importance of understanding childhood depression as an entity distinct from depression in adults. This is due to the fact that developmental issues in childhood are distinctly different from those of adulthood.
A model of childhood affective disorders uses the following explicit criteria:
- Dysphoric mood (children younger than 6 years must also have a sad facial expression).
- At least 4 of the following signs or symptoms present every
day for a period of at least 2 weeks:
- Appetite disturbance.
- Insomnia or hypersomnia.
- Psychomotor agitation or retardation.
- Loss of interest or pleasure in usual activities (children younger than 6 years must also have signs of apathy).
- Fatigue or loss of energy.
- Feelings of worthlessness, self-reproach, or excessive, inappropriate guilt.
- Diminished ability to think or concentrate.
- Recurrent thoughts of death or suicide.
Management of Pediatric Depression
Treatment regimens implemented in childhood depression reflect theoretical models, etiology, and manifestations of the disorder. Individual and group psychotherapy are commonly utilized as the primary treatment modality and are directed at helping the child to master his or her difficulties and to enable the child to develop in an optimal manner. Play therapy may be used as a means of exploring a younger child's view of himself or herself, the disease, and its treatment. The child needs to be helped from the beginning to explore and understand, at a level appropriate for his or her developmental age, the diagnosis of cancer and the treatments involved.
As is the case with depression in adult cancer patients, there are few, if any, revealing trials of antidepressants in children with cancer. One author described rapid clinical response to low doses (<2 mg/kg/d) of imipramine or amitriptyline for eight depressed children with cancer.[Level of evidence: III] Another author described the use of benzodiazepines such as lorazepam, diazepam, alprazolam, and clonazepam for the treatment of anxiety disorders. Trials of benzodiazepines should be short term. These drugs should be tapered slowly when they are discontinued.
The combined use of tricyclic antidepressants and neuroleptics in the management of three children with severe symptoms of depression and anxiety has been reported. The children studied were in the terminal phases of their disease and were treated with a combination of low-dose amitriptyline and haloperidol. Levels of anxiety and depression were decreased, and this intervention allowed the patients and their families to deal with issues involved in death and dying.[Level of evidence: III]
Refer to the subsection on Depression and Suicide in the PDQ summary on Pediatric Supportive Care for information on pediatric considerations for suicidality and cautions about the use of selective serotonin reuptake inhibitors.
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