The past year has been an enormous mental health challenge for children and adolescents. Research in Child Adolescent Health indicated the global closures of schools and colleges due to the COVID-19 pandemic have negatively impacted over 91% of the world’s student population. Children found their levels of boredom increasing and motivation decreasing as schedules were upended, soccer practices were canceled, and school lunches went virtual.
With these lifestyle interruptions came an alarming increase in rates of pediatric depression.
I’ve seen the challenges pediatricians are facing firsthand and hope to provide some insight into what these new mental health challenges entail, how providers can screen for depression in primary care, and strategies for treating pediatric depression.
Research indicates pediatric depression is increasing
The percentage of children and adolescents exhibiting health risk behaviors — including suicidal ideation, making a suicide plan, attempted suicide, and suicide attempts requiring medical treatment — have increased significantly since 2011 and have accelerated with the pandemic. A survey of 1000 high school and college students indicated that almost 25% knew a peer who had developed suicidal thoughts since the onset of COVID-19. And, more than 50% of respondents in a survey of high school and college students reported they were worried about their own mental health during the pandemic.
These statistics are generally elevated for any children who identify as members of marginalized communities, with LGBTQ+ youth reporting health risk behaviors at the highest rate.
Unfortunately, the concerning increase in rates of pediatric depression will not simply go away as vaccines become available. A systemic review of 63 studies found that a surprising impact of social isolation and loneliness was prolonged risk of depression and anxiety up to nine years later. Additionally, the duration of loneliness was more strongly associated with mental health symptoms than the intensity of loneliness. Even as we climb out of the quarantine period and the COVID-19 pandemic, we should expect this prolonged trauma period to affect children for years to come.
Screening for pediatric depression is quick, free, and easy
The DSM-5 contains information about the full spectrum of common depressive disorders in children. But, one of the most common disorders you might run into is Major Depressive Disorder (MDD).
To screen for MDD, you can provide questionnaires specific to both parents and children at general visits and interpret their responses. You’ll find patients with MDD report depressed mood or loss of interest or pleasure in addition to five or more Major Depressive Disorder symptoms within the same two-week period.
You can use the patient’s age to determine which screening is most fitting between the Pediatric Symptom Checklist/Pediatric Symptom Checklist Youth Report (PSC and Y-PSC) and the Patient Health Questionnaire 9 (PHQ-9). Here’s how they compare:
- Screens for cognitive, emotional, and behavioral problems
- For youth between 4-16
- Takes 5-10 minutes to complete
- Specific to depression
- For ages 12 and up
- Takes 5-10 minutes to complete
After children take either screening questionnaire, staff will score the questionnaire responses and determine whether MDD possibility is positive or negative. Of course, you should also conduct a formal assessment — including a clinical interview and symptoms rating scales — before moving forward with MDD treatment.
The patient and family-first approach to treating Major Depressive Disorder
The severity of a patient’s MDD diagnosis will direct the treatment plan:
- Treating subclinical to mild depression includes supported self-management and follow-up conversations to help the children understand how they can make themselves feel better – including how sleep and nutrition can affect their depression.
- Treating moderate depression (and mild depression that does not respond to supported self-management) includes therapy referral and an optional medication trial.
- Treating severe depression requires a therapy referral and medication.
While some families may be hesitant about one method or the other, studies indicate that a combination of therapy and medication trials will help children with severe depression improve faster.
However, as a pediatric provider, it’s important to remember how scary these conversations can be for families and set clear expectations for what families and patients can anticipate throughout the treatment process.
Steps for setting family expectations include:
- Screening for family history of Bipolar Disorder and suicide.
- Communication plans for both regular follow-up and emergency access visits.
- Family education about the length of adequate trials to reduce the risk of non-compliance.
- Emphasizing that the family should alert pediatricians about worsening depression or suicidal thoughts.
- Explanation of mania to set family expectations for this common side effect of MDD medication.
- Ongoing informed consent to continue educating families and improve treatment outcomes.
SSRIs: the gold standard
As far as medication is concerned, SSRIs (Selective Serotonin Reuptake Inhibitors) are the gold standard of care for pediatric depression. 70% of patients respond to their first SSRI, and of the patients who do not respond, 70% respond to the second SSRI.
Generally speaking, Fluoxetine, Escitalopram, and Sertraline are the most common SSRIs, with Fluoxetine being the oldest and most well-known SSRI. Whenever you’re treating a new patient or prescribing an SSRI to a child who has never taken one before, you should always conduct test doses first to understand how patients will respond to specific medications. Then, it’s important to make sure any resulting SSRI treatment plan you develop includes periodic monitoring for side effects and reassessment of patients using screening tools at recommended times throughout the treatment plan.
Next steps: resources for providers and families
Every patient and family has different needs, but, fortunately, there’s a wealth of knowledge and research around pediatric depression that can help you make the right choices for your patients.
Here are just a few of my favorite resources for providers and families:
- aacap.org and aap.org include practice parameters, with a lot of facts for families — including brief summaries explaining what to expect from pediatric mental health treatments.
- parentsmedguide.org is a collaborative effort by the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association. These sites share practical information and advice regarding pediatric depression and anxiety for parents, patients, and clinicians.
- schoolpsychiatry.org is a publication by Mass General and provides valuable screening tools.
As always, Iris Telehealth is here as a resource for providers who need support. If your organization is feeling the weight of increased numbers of patients experiencing pediatric depression, contact us today. We’d love to talk to you about the difference telepsychiatry can make in your practice!