Information for Professionals
Depression and dysthymia are common disorders in adolescents and are well recognised in older children. Often symptoms begin at the time of a loss or change that is significant to the young person and distinguishing a normal process of transition from a depressive disorder is mainly based on the severity and duration of symptoms compared with normal sadness or distress for that child or adolescent’s age. If a child or adolescent has ongoing sad or lowered (or in teenagers, irritable) mood or lack of enjoyment of activities they usually find fun for over two weeks then depression needs to be considered. Suicidal thoughts or behaviour and psychotic symptoms indicate a severe disorder. Dysthymia refers to a lower grade sadness or lack of enjoyment that goes on for at least six months.
Referral to a child and adolescent psychiatrist may be useful when the diagnosis is unclear and is indicated when first line treatments are not effective, symptoms are severe or when second or third line treatments are being considered.
Assessing and addressing safety concerns, both in terms of risks to the child or adolescent from child abuse or neglect as well as thoughts or actions of suicide or harming others are essential parts of the initial assessment. This includes a safety plan for young people with suicidal thoughts or behaviours, that includes them and their parent/s or where the parent is unable to do this, another responsible, adult carer.
For some adolescents and children, milder depressive disorders may improve with regular exercise, education for them and their families about the nature of the difficulties and realistic hope for improvement, increasing pleasant activities and/or mindfulness practices.
Where there are more than mild symptoms or these do not resolve promptly, treatment for depression in older children and adolescents has been shown to be effective with Interpersonal Psychotherapy and Cognitive Behavioural Therapy that includes parent involvement and there is promising research in some forms of Family Therapy. When these are not available or not sufficient, fluoxetine1 or another selective serotonin re-uptake inhibitor may be appropriate.
Discussing and making or revising the safety plan around the possibility of a transient increase in agitation or suicidal behaviour is indicated when starting treatment with an antidepressant, noting that a lack of any treatment is a far greater risk for completed suicide in depression overall.
In younger children, addressing family difficulties, parent-child relationship distress and parental wellbeing are central to treatment and medication for the child is rarely appropriate. In all age groups, ensuring safety for the child and those around them is necessary for treatment to be effective.