Clear safety plans are essential for the families of children with depression. Families must be educated about the need to remove weapons and other means of carrying out lethal intentions (e.g., prescription medications, OTC medications, poisons, alcohol, ropes) from the home. Families must also be taught about the signs and risks of suicide. In the case of an adolescent or an older child, families may make an oral or verbal contract that spells out who the patient will notify if his or her suicidality or depression increases.
2 Recognize that treatment of a child or adolescent with depression includes active participation of the whole family in any management plan.
Although rare, serotonin syndrome is life-threatening, and children need emergency care if symptoms (e.g., fever, elevated pulse and BP, agitation, or delirium) develop. The risk of serotonin syndrome is greater with drug overdose, concurrent use of more than one SSRI, or taking an SSRI along with another antidepressant or St. John's wort. The combination of an SSRI with a monoamine oxidase inhibitor (MAOI) is especially dangerous.
Another group of drugs prescribed for adults are the so-called atypical antidepressants, a term used for newer drugs with varying pharmacologic actions. For some, the mechanism of action is unknown. Examples include bupropion (Wellbutrin), venlafaxine (Effexor), mirtazapine (Remeron), and duloxetine (Cymbalta). Although widely advertised and commonly prescribed for adults, there are not enough data to consider these medications to be first-line agents in children and adolescents, and the PCP should not prescribe them without consulting a specialist.
Two drug classes that should never be used in primary care are the tricyclic antidepressants (TCAs) and the MAOIs. Both classes have major safety problems, and neither has established effectiveness in the treatment of childhood depression.11 TCAs have many side effects and drug interactions, and overdose is potentially fatal. MAOIs are notorious for multiple drug and food interactions, and failure to follow dietary modifications can result in serious complications (e.g., stroke). Overdose and interaction with other antidepressants carry a high risk of lethality.
Putting it all together
Childhood depression is probably overlooked more than it is diagnosed and treated, and PCPs are often the first to identify the warning signs. Untreated childhood depression can adversely affect growth and development, increase the risk for substance abuse and other dangerous behaviors, and result in death by suicide. All PCPs should be able to recognize signs of depression and institute a basic plan that provides for safety, a therapeutic relationship, and ongoing social support for the patient. Referral to mental-health specialists is indicated for professional psychotherapy and must be considered if the PCP is uncertain about how to proceed once initial treatment fails or if the child's situation is potentially life-threatening. By virtue of an established relationship with children and their parents and the extensive background knowledge of the patient, PCPs can bring about positive outcomes for depressed children and adolescents.
Dr. Garzon is a pediatric nurse practitioner and assistant professor at the University of Missouri-St. Louis College of Nursing. Dr. Nelson is teaching assistant professor at the University of Missouri-St. Louis College of Nursing. Ms. Figgemeier is a pediatric nurse and graduate nurse practitioner student at the University of Missouri-St. Louis College of Nursing.
References
1. American Academy of Child and Adolescent Psychiatry. Depression in Children and Adolescents. Washington, D.C.: American Academy of Child and Adolescent Psychiatry: 2004.
2. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120:e1299-e1312.
3.Centers for Disease Control and Prevention. Web-based injury statistics query and reporting syystem (WISQARS).
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.; American Psychiatric Association: 2000;356
5. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.
6. Emslie G, Kratochvil C, Vitiello B, et al. Treatment for Adolescents with Depression Study (TADS): safety results. J Am Acad Child Adolesc Psychiatry. 2006;45:1440-1455.
7. U.S. Food and Drug Administration. Suicidality in children and adolescents being treated with antidepressant medications.
8. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297:1683-1696.
9. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313-e1326.
10. Singh MK, Pfeifer JC, Barzman DH. Medical management of pediatric mood disorders. Pediatr Ann. 2007;36:552-563.
11. Hazell P, O'Connell D, Heathcote D, Henry D. Tricyclic drugs for depression in children and adolescents. Cochrane Database Syst Rev. 2002;(2):CD002317.
All electronic documents accessed September 16, 2009.