Approximately five percent of children and adolescents in the United States suffer from depression, which is often undiagnosed or untreated.1 Untreated depression can have a serious impact on growth and development, yet the symptoms of almost two-thirds of children with depression go unrecognized by their primary-care provider (PCP), and only half of those whose depression is diagnosed receive adequate treatment.2 Childhood depression
causes young patients to withdraw from activities. This may result in academic delays related to poor school performance, lost friendships, impaired social skills, interpersonal conflicts, and family dysfunction. The most serious complication of depression is attempted or completed suicide. 

The incidence of successful suicide in older children and adolescents is alarming. In 2005 alone, 4,482 young people between 10 and 24 years of age committed suicide, making it the third leading cause of death in this age group.3 In fact, suicide resulted in more deaths than the next four causes combined.3 Because of their frequent contact with children and adolescents, PCPs are in an ideal position to recognize the warning signs of depression and provide initial management.

Assessment and diagnosis

There are three types of childhood depression: major depressive disorder, dysthymia or dysthymic disorder, and bipolar affective disorder. Because the symptoms tend to be different than those seen in adults, diagnosis can be difficult. The hallmark of major depressive disorder (MDD) is a sad or depressed mood for at least two weeks. In children, the mood is most often described as irritability that manifests in various behavior problems. Younger children are likely to have somatic complaints (e.g., headache, upset stomach), leading the PCP to treat these symptoms without realizing they are signs of depression. Adolescents may engage in risky behavior (e.g., alcohol and drug use, dangerous driving, promiscuous sex) or antisocial behavior (e.g., stealing, vandalism, running away from home). They may become socially withdrawn or aggressive, or they may hurt others. Diagnosis is based on criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).4

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Dysthymia or dysthymic disorder is a chronic depression that does not meet full MDD criteria and is present on most days for at least one year. Symptoms tend to be less life-threatening than those seen in MDD, but they are significant enough to interfere with the patient’s general functioning and do warrant treatment.

Depression is one manifestation of bipolar affective disorder (BAD), previously called manic depressive disorder. Depressive incidents in BAD resemble those seen in MDD, but they eventually progress to episodes of mania that alternate with depression. When screening for depression, assess for any history of mania, since this is the primary difference between BAD and MDD.4 Unfortunately, if the patient presents with depression and has no history of manic episodes, BAD may be difficult to detect. Nevertheless, keep this differential diagnosis in mind, especially if treatment with antidepressant drugs results in agitation or other manic symptoms. BAD requires more complex pharmacologic management, and patients need referral to a psychiatric specialist. An additional concern with BAD is that the symptoms of mania resemble those of attention-deficit hyperactivity disorder (ADHD), and treatment with central nervous system stimulants or other drugs commonly used in ADHD can intensify mania. Children whose symptoms worsen on ADHD therapy need a psychiatric evaluation that includes screening for mood disorders.

Any child who is at high risk for depression or who presents with emotional problems as a primary complaint should be screened for depression.2 Evaluating a child or adolescent for depression requires sufficient time for a thorough assessment and must include interviews of both the child and the family/caregivers. A complete history, physical examination, and battery of lab tests (Table 1) are needed to determine general health status and rule out medical problems with symptoms that can mimic depression (Table 2). Be aware of drugs that can cause depressionlike symptoms. These include antiseizure medications, sedatives, prednisone, beta blockers, oral contraceptives, nonsteroidal anti-inflammatory drugs, and stimulants. Screening for depression can begin with asking such open-ended questions as, “How are things going for you at home?” or “How is everything at school this year?” More direct questions are appropriate to elicit the presence or absence of specific depressive symptoms. However, specific instruments or questions that relate to DSM-IV criteria are necessary to correctly diagnose children (Table 3).

Assess for suicidal ideation in a direct manner. Ask the patient: “Are you thinking about hurting or killing yourself?” Depending on the response, other questions may be indicated, such as: “Do you have a plan?” and “How would you carry out this plan?” Expressed thoughts of suicide must always be taken seriously and require immediate referral to a mental-health specialist.