CHILDHOOD DEPRESSION

Sourced From Dr. Rajesh Sagar - AIIMS (Delhi)



Depression

Everyone experiences sadness at times, but depression is something more. Depression is a disorder in which a person feels persistently low or sad, irritable, lack of interaction, or lack of interest with easy fatigability in some physical activities. Routine or daily activities are become hard task, may having physical pain and suicidal thoughts. Depression is often disabling in nature and may exhibit a chronic course including a spectrum of signs and symptoms. It varies in its severity (mild to severe) and duration.
Recent studies estimated that the depressive disorders affect 4.4% of the world population and more common in females (5.1 %M vs 3.6 %F). In India, NMHS survey (2015-16) reported that 5.25 % of adult population (1 in 20) have ever suffered from depression, at least once in their lifetime and a total of more than 45 million people are having depression in 2015.

Childhood Depression

Depression was not widely accepted in children as a mental health issue until the 1970’s, as it was thought that due to lack of personality structure children were not able to experience depression and also diagnostic criteria was lacking for children. The concept changed after the Fourth Congress of Pedo-psychiatrist (held in 1970) having the theme- ‘Depressive states in childhood and adolescent’.
Childhood depression is a disabling, familial disorder with recurrent course, mild to moderate in severity and poor psychological outcome. Anxiety and disruptive disorders are significantly present as co- morbid with childhood depression with increase risk for suicidal behavior and substance abuse. Presenting symptoms of childhood depression are persistently sadness, increase tantrums and irritability, crying, tearfulness, physical pain, disturbed family and peer group relationship along with poor academic performance.
Childhood major depression occurs at the same rate in girls and boys, but the ratio is 2:1 in adolescent as similar to adults. Major childhood depression has prevalence of 18%. Dysthymic disorder is a milder form of depression which also prevalent in children and impact their performance at school and home. The NMHS survey (2015-16) reported 0.8 % of prevalence for childhood depression in India.

Causes and risk factor

Multiple factor are responsible for aetiology of any mental disorder as well as depression There is no single identifiable cause but several biological, familial/social, economical, cultural and environmental factors operate in a maladaptive manner resulting into depression.

Causes and risk factor

About 1/3rd of depression cases have genetic basis and rest are due to environmental factors. Although specific genes or gene– environment association are yet to be established, but an association between early childhood traumatic experiences and genetic vulnerability to depression is known to exist. Similar early life trauma events having different outcome in different children are again shows some genetic basis. Deficiency of neuro-chemicals like nor- adrenaline and serotonin are also having role in the pathogenesis of childhood depression.

Psychological factors

Exposure to condemning or poor parenting style, critical and negative comments during early childhood may be associated with negative feelings and self thus give rise to depression. Early loss of attachment bond with mother or separation may lead to depression

Social factors

Broken and disturbed social as well as familial and parental relationships have been associated with origin of depression. Globalization, migration and urbanisation compromises social support system leading to social isolation, which increases the mental health problems including depression.

Cultural factors

Culture and religion, attitude and belief system has significant role in mental health issue. Different socio- cultural contexts and coping style has role in origin of depression.

Economic factors

Persons with poor economical status, sudden economical losses or crisis are more prone to developing depression. Children living in shortage, at refugees’ camp or at places of natural disaster are also more vulnerable to develop depression to a greater extent.

Diagnosis

There are different types of depression. Depending on the symptoms and illness severity, age and socio cultural context depression often manifests in varied presentation.

Diagnostic criteria for depression (simplified ICD- 10)

The symptoms remain for at least 2 weeks for the diagnosis of depression

Major symptoms

Feeling low or sad most of the day, nearly every day
Markedly reduced pleasure and interest in almost all the activities, most of the day, nearly every day
Loss of energy or fatigue nearly everyday

Minor symptoms

Loss of self esteem, low self confidence, excess feeling of guilt nearly everyday
Recurrent thoughts of suicide or death, or suicidal attempts
Decrease concentration, disturbed sleep nearly everyday
Pessimistic view of future, disturbed appetite and weight

One of the problems in childhood depression is under-detection. The symptoms are not just similar to adult depression and the condition may be present with co- morbidities also like conduct problems, ADHD, somatic complains etc. The common symptoms seen in childhood depression are:
Frequent sadness, tearfulness, and/or crying
Persistent boredom, low energy
Increased temper tantrums, irritability, anger
Poor communication with peer group, difficulty with relationship
Extreme sensitivity to rejection or failure
Decrease interest in activities or inability to enjoy previously favorite activities
Frequent complaints of physical pain or illnesses such as headache
Major change in eating and sleeping behavior
Thoughts or acts of suicide or self destructive behavior

Scales used for measuring childhood depression

Depression and Anxiety in Youth Scale (DAYS)
Children’s Depression Rating Scale-Revised
Child Depression Inventory
Beck Depression Inventory for Youth

Management

Awareness about childhood depression as well as reduction of stigma and discrimination through IEC and community mobilization must be conducted to ensure the find out cases and their proper management. Preventive and promotive massages as well as health promotion should be done. Awareness activities about societal problems that act as risk factor for depression (such as domestic and sexual violence, child abuse, substance abuse etc.) are conducted in community to reduce the burden of these disorders.

Multimodal approach is usually considered. Treatment consists of psychotherapy or pharmacotherapy or a combination depending on the severity of the condition. Hospitalization may be necessary for children and adolescents who are depressed and express suicidal thoughts or behaviours; coexisting substance abuse or dependence.

Psychotherapy

Psychotherapy is one of the most intensive forms of psychological interventions. It includes:
Self control training
Problem solving training
Relaxation training

Psychotherapy

Multimodal approach is usually considered. Treatment consists of psychotherapy or pharmacotherapy or a combination depending on the severity of the condition. Hospitalization may be necessary for children and adolescents who are depressed and express suicidal thoughts or behaviours; coexisting substance abuse or dependence.

Cognitive behaviour therapy (CBT)

Cognitive behaviour therapy is effective for mild to moderate childhood depression. Identify and challenge automatic, distorted thoughts; engage in activities that provide evidence disproving dysfunctional beliefs; modify core beliefs by reviewing evidence.

Interpersonal psychotherapy

is directed at resolving grief, coming to terms with interpersonal role transitions or role disputes, and correcting interpersonal skill deficits.

OPD based counselling may involve- educating the patients about healthy coping skills, conflict resolution, problem solving and relaxation techniques; Parent education about age appropriate and realistic expectations, non critical and non judgemental communication; healthy behaviours, and relationships. Behavioural techniques-

Pharmacotherapy-

The risk/benefit ratio of antidepressant use should be considered. Physicians must obtain fully informed consent to choosing and prescribe antidepressants and clinical progress must be monitored. Look for behavioural activation (e.g., impulsivity, daring, silliness, agitation), hypomania or switch and suicidality, especially in the initial stages of treatment. There are several medicines available for treatment of depression. However, consultation with family doctor or psychiatrist will decide about the specific medicine and its duration. In general, almost all persons with depression get recovered if early identification of depression is made with proper consultations and regular follow up with doctors or mental health professionals.

(The author is professor, department of psychiatry, All India institute of Medical Sciences, Delhi)