Behavioral Issues

Depression and Suicide

 

Background

Childhood and adolescent depression is a significant but often under-recognized threat to the wellbeing of youth. It is easy to miss because of its variable presentation and the frequent attribution of irritability and moodiness to normal adolescence. However depressive disorders are common and disabling in pediatric populations. Understanding them, recognizing them, and taking measures to help prevent the drastic consequences of major depression is the responsibility of the health care team, parents, teachers, and community leaders that interact with at-risk children.

Depression

Major Depressive Disorder (MDD) is recognized by the World Health Organization as one of the "most disabling of all diseases in the world." MDD is defined in the DSM-5 (Diagnostic and Statistical Manual for Mental Disorders) as follows:

At least one of the following 2 symptoms must be present to make the diagnosis:

  • depressed or irritable mood
  • loss of interest or pleasure (anhedonia)           

And either 3 or 4 of the following:

  • Decreased/increased appetite, weight loss/gain, failure to achieve expected weight gain (especially important in kids)
  • Insomnia/hypersomnia
  • Psychomotor agitation/restlessness or motor retardation
  • Low energy or fatigue
  • Feelings of worthlessness or excessive guilt
  • Indecision, poor concentration and memory
  • Recurrent thoughts of death or suicide

At least 5 symptoms are present during the same 2 week period, occur almost every day, and represent a change in functioning. These symptoms are not better explained by any other diagnosis or a general medical condition.

Epidemiology

  • Children can be depressed at any age, with higher rates in older children. 
  • In the US, 1% of preschoolers, 2% of school-age children and 5-8% of adolescents have MDD at any one time.
  • Over the past several decades, the prevalence of MDD has risen along with onset at younger ages. 
  • Before puberty the gender ratio for depressive disorders is 1:1.
  • After puberty there is a 2:1 female-to-male ratio.  This continues into adulthood.
  • 50% of children and adolescents who have MDD will have recurrences as adults.

Suicide is the 3rd leading cause of death in children and adolescents.

  • 80% of youth who attempt suicide and 90% of youth who complete suicide have a history of a psychiatric or mental disorder: this includes depression, substance abuse, conduct disorder, aggressive behavior patterns, and anxiety disorders.
    • 50% of adolescent males and 66% of adolescent females who successfully commit suicide suffered from depression.
  • 32% of depressed youth will have at least one suicide attempt before adulthood
  • 85% of depressed youth have significant suicidal ideation
  • Firearms are the leading cause of death by suicide for both males and females
  • Suicide rate for ages 5-14 years: 0.8 per 100,000
  • Suicide rate for ages 15-24 years: 11.1 per 100,000
  • Prevalence of Suicidal Ideation in adolescents (15-19 yrs): M 11-14%, F 18-25%
  • Prevalence of Suicidal Attempts in adolescents: M 4-6%, F 11%
  • Prevalence of Completed Suicide in adolescents: M 13.3/100,000, F 2.8/100,000

Risk Factors for Depression

  • Often interaction of genetic and environmental factors
  • Parental depression is strongest genetic factor 
  • Environmental factors:
    • Maltreatment (sexual, emotional or physical abuse and neglect)
    • Parental substance abuse
    • Low socioeconomic status and education level
    • Major life stressor (loss of loved one, parents get divorced, breakup with boyfriend/girlfriend, etc.)
  • Other factors include certain medications (e.g. glucocorticoids, immunosuppressives, isotretinoin, antivirals) and chronic illness

Differential Diagnosis for Major Depressive Disorder

  1. Bipolar disorder
  2. Dysthymic disorder (often overlooked, but can casue as much, or more impairment in function than MDD due to extended course)
  3. Substance abuse (often comorbid; can also be cause or effect of MDD)
  4. Anxiety disorder (often comorbid, especially in girls)
  5. Conduct disorder (often comorbid, especially in boys)
  6. Mood disorder related to a medical condition (hypothyroidism, Addison's disease, postconcussive syndrome, Vit B12 deficieincy,  SLE, Mononucleosis, HIV)
  7. Bereavement
  8. Adjustment disorder with depressed mood
  9. Post-traumatic stress disorder (often comorbid, especially in boys)
  10. Attention-deficit hyperactivity disorder (often comorbid)

Between 40-70% of depressed children and adolescents have comorbid psychiatric disordrers

Risk Factors for Suicide

  • Strongest predictor of future suicidal behavior = history of previous attempt
  • Suicidal ideation
  • Exposure to someone who also attempted or completed suicide (friend/family)
  • Current Depressive Disorder, Bipolar disorder, Substance Abuse, Conduct Disorder or other psychopathology
  • Aggressiveness, impulsivity, hopelessness (sign of depression)
  • Lack of connectedness with parents
  • Parent with substance abuse problem or psychopathology
  • History of physical/sexual abuse, violence, or conflict
  • Homosexual orientation
  • 42% of gay, lesbian, bisexual adolescents experience suicidal ideation
  • 28% have attempted suicide at least once in the past year
  • Access to firearms, toxic chemicals or medications, or other means
  • History of adoption

Protective Factors Against Suicide

  • Parenting skills that emphasize praise for positive behavior
  • Increase in amount of time that parents spend with children
  • Strong parent-family connectedness
  • Restricted access to guns or other weapons
  • Restricted access to alcohol, marijuana, or other drugs

How to Approach an Adolescent who may be at risk for Suicide

  1. Know the risk factors.
  2. Ask about suicidal ideation. Is there a plan? Intent? Access to a weapon? Has it happened before? What happened?
  3. Ask about firearms in the home. Recommend that they be removed.
  4. Recognize signs of depression. This may present in typical form: insomnia or hypersomnia, change in weight, depressed mood, feelings of helplessness. However, in adolescents, it often presents in other ways such as behavioral problems (truancy, violence, self-destruction, running away from home, sexual acting out, etc.), difficulty with academic performance, or psychosomatic complaints (abdominal pain, headache, dizziness, chest pain, etc).
  5. Recognize the psychiatric needs of an adolescent with signs of risk for suicide. If the patient admits to a having a plan or has a history of a previous attempt and is now exhibiting warning signs of a repeat attempt, this patient should get an immediate psychiatric evaluation and probably be admitted to an inpatient unit until his/her safety is no longer at risk. Hospital stays are usually brief and are meant to stabilize and evaluate the patient and arrange for close follow-up.

Treatment

MDD treat_0.pnghttps://www.nimh.nih.gov/health/statistics/major-depression.shtml

  1. Pharmacotherapy: SSRIs (Selective Serotonin Reuptake Inhibitors) are the antidepressants of choice for young people with depression. Fluoxetine is the only FDA approved medication for pediatric patients although other antidepressants are used off label. These drugs may take 4-6 weeks to take effect. Unless there are significant adverse effects from the drugs, SSRIs should be continued for 6-12 months to help achieve remission from the depression. CAUTION: There is a small but real increased risk of suicidal thoughts or behavior (but not completed suicides) in children taking antidepressants compared with placebo. This effect is hypothesized to be due to an increase in energy which is not yet balanced by improved feelings of emotional well-being.  Most mental health specialists agree that, if indicated, the benefits of antidepressants therapy outweigh the risks. (See page on Antidepressants)
  2. Psychotherapy: Cognitive-Behavioral Therapy (CBT) and Interpersonal Therapy may be useful in helping youth learn to cope with and overcome depression. Family therapy may also be useful.
  3. Combination Therapy: Pharmacotherapy plus psychotherapy has been shown to be most beneficial for patients. 

Patients should have close follow up and continue to be monitored for risks of suicide. Make sure the patient and his/her guardians are aware of accessible 24-hour emergency services.

Resources for Patients and Families

Follow the links and click on the logos for more information.

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SAMHSA provides a Behavioral Health Services Locator as well as a national helpline at 1-800-662-HELP (4357).

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NAMI is the largest grassroots mental health organization in the US. It works to raise awareness and provide education and support to patients, their families, and healthcare providers.

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There are many support groups and online communities offered by organizations such as Depression and Bipolar Support Alliance and OK2TALK.

More information and resources can be found on the American Academy of Child & Adolescent Psychiatry and Health & Human Services websites.

References

  1. Committee on Adolescence. Suicide and Suicide Attempts in Adolescents. Pediatrics             2000; 105:871-874.
  2. Borowsky, Iris W. Adolescent Suicide Attempts: Risk and Protectors. Pediatrics        Mar 2001; 107: 485-493.
  3. Woods, Elizabeth R. The Associations of Suicide Attempts in Adolescents. Pediatrics            June 1997; 99:791-796.
  4. Friendman R.A. Uncovering an Epidemic-Screening for Mental Illness in Teens.  NEJM Dec 28, 2006
  5. March J. et. al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized control trial.  JAMA 2004;292:807
  6. Hammad, TA et. al. Suicidality in pediatric patients with antidepressant drugs.  Arch Gen Psychiatry 2006;63;332

  7. Prager, L. M. Depression and Suicide in Children and Adolescents. Pediatrics in Review 2009; 30:199–206. 

  8. Mullen, S. Major depressive disorder in children and adolescents. Ment Health Clin 2018; 8:275–283.

  9. Bonin, L. Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis. D Solomon (Ed.), UpToDate. Updated December 6, 2019. https://www.uptodate.com