Depression
Guidance for primary care clinicians diagnosing and managing children with depression
Depression is common. By age 18, an estimated 1 in 5 youth will have experienced at least 1 episode of depression. [Merikangas: 2009] [Bitsko: 2018] Depressive disorders are characterized by sad, empty, or irritable mood accompanied by somatic and cognitive changes that significantly impact an affected individual’s capacity to function. The category of depressive disorders includes major depressive disorder (MDD), disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, and other specified or unspecified depressive disorders. [American: 2022] The various depressive disorders differ primarily by timing, duration, associated symptoms, and etiology. This module focuses on major depressive disorder (MDD) and provides valuable information for diagnosing and treating other depressive disorders.
Primary care pediatric clinicians are often the first line in evaluating and successfully treating depressive disorders. Routine and universal screening for MDD in adolescents is critical for preventing the incidence of this disorder into adulthood. [Avenevoli: 2015]
Key Points
Assess for suicidality
Assessment for depression must always include assessment of current
and past suicidality. If a patient expresses suicidal thoughts, providers must take
measures immediately to ensure the child’s or adolescent’s safety. Suicidality & Self-Harm.
Depression in children with complex health care needs
About 1 in 5 children have special health care needs. Of those
children and youth with special healthcare needs, 17-23% are affected by
depression compared to 5-9% of other children. [Parmar: 2021] Children and adolescents with developmental delays can also
develop depression. Always consider the child's developmental level when looking
for behaviors and changes in mood that might signal a depressive disorder. For
more detail on how depression can present in different childhood developmental
stages, see Presentations below.
SIGECAPS
SIGECAPS is a commonly used mnemonic for the symptoms of
depression that can occur in addition to depression:
- S – sleep
- I – interest
- G – guilt
- E – energy
- C – concentration
- A – appetite or weight
- P – psychomotor changes
- S - suicidality
Irritability as a presenting feature of depression
Although depressed/sad mood is the most common mood reported in youth
meeting criteria for depression, irritable mood is also common. It may occur
concurrently with depressed mood (35.6% of cases) or alone (5.7% of cases).
[Stringaris: 2013]
Antidepressants and suicidality
Antidepressant medications may cause mood changes and therefore need
to be monitored closely. Providers must counsel caregivers and youth about the
increased risk of suicidal thoughts or behaviors when taking an antidepressant. In
antidepressant studies, about 4% of children and adolescents had worsening suicidal
thoughts or behaviors (compared to 2% with a placebo). However, in over 4000
subjects studied, there were no (0) completed suicides. [US: 2018] An independent review of available data by the American Medical
Association indicated that “a causal role for antidepressants in increasing suicides
in children and adolescents has not been established. Concerns that antidepressants
potentiate suicidal or self-injurious behavior need to be balanced by the clear risk
of suicide in children and adolescents with untreated depression.” [Jane: 2016] There is also data demonstrating a correlation between
higher rates of SSRI prescriptions and reduced child and adolescent suicide rates.
[Gibbons: 2006] Refer to the section below for more
information about antidepressants and suicidal adverse events (SAEs).
Medication monitoring
Check for interactions with other prescriptions, over-the-counter
medications, herbal medications (such as St. John’s wort and valerian root), and
dietary supplements (such as S -adenosylmethionine (SAMe), hydroxytryptophan
(5-HTP), and saffron). When prescribing antidepressants, be aware of the
prescribed agent’s side effects and risks of serotonin syndrome and
antidepressant discontinuation syndrome. See the sections on Serotonin Syndrome
and Antidepressant Discontinuation Syndrome below for more information.
Treatment duration
- Four to six weeks of adherence is required to assess a dose’s full effect and determine if the dose is adequate, although some people may feel a benefit in less time.
- The general recommendation for therapy and medications is that they are continued for at least 6-12 months from symptom improvement because depressive episodes can last from months to years.
- Up to 70% of adolescents with major depression will experience some degree of recurrence within 5 years and may need to restart treatment.
The roles of psychotherapy, medication, and psychiatry
While the most effective treatment for moderate to severe depression
combines psychotherapy and antidepressant medication, in cases of mild to moderate
depression, psychotherapy alone may be a reasonable treatment option. [March: 2007] Providers should make this decision in collaboration
with the patient and family. It may take longer to realize the positive effects of
psychotherapy compared to medication. Failure to improve with adequate treatment
trials is a criterion for consultation with, or referral to, a qualified child and
adolescent psychiatrist.
Practice Guidelines
Walter HJ, Abright AR, Bukstein OG, Diamond J, Keable H, Ripperger-Suhler J, Rockhill C.
Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive
Disorders.
J Am Acad Child Adolesc Psychiatry.
2023.
PubMed abstract
Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment,
and Initial Management.
Pediatrics.
2018.
PubMed abstract
Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.
Pediatrics.
2018.
PubMed abstract
Diagnosis
History
Family History
Presentations
Depressive symptoms in infants may include sadness, inactivity, withdrawn behavior, agitation, sleep problems, feeding problems, and failure to thrive. A major controversy is whether symptoms may occur endogenously or are always associated with environmental stress (separation from caregivers, maternal depression, neglect, abuse, severe illness). Such symptoms should prompt a search for environmental causes or physical conditions. Diagnostic criteria for depression in infancy are available in the Classification of Mental and Developmental Disorders (Zero to Three). The proper diagnosis and treatment of such cases warrant referral to a specialist. There is no data on treatment in this age group, but providers and families should consider environmental interventions as appropriate.
The prevalence of depression in preschoolers is approximately 2%, based on available studies. [Whalen: 2017] Depressive symptoms may include those listed above for infants, as well as the child’s stated emotions (e.g., “I’m sad”) or observation of depressive themes in the child’s play (e.g., themes of sadness, loss, guilt, aggression, death, or suicide). Somatic symptoms (e.g., headaches, stomachaches) may be present but are less frequent than more typical depressive symptoms. [Luby: 2003] Endogenous depression is less controversial in this age group, but environmental factors are still important. As with infant depression, diagnostic criteria are available that have been modified to reflect developmental stage and include decreased number and duration of symptoms. [Luby: 2003]

The prevalence of endogenous depression in school-age children is thought to be 1-2% with a 1:1 male-to-female ratio. [Costello: 2003] Diagnosis is based on DSM-5-TR criteria. [American: 2013] The criteria for depression in children are the same as adult criteria except for the inclusion of irritable mood in addition to depressed or sad mood. School-age children are more able than younger children to report their symptoms and commonly present with temper tantrums, increased frustration and irritability, and somatic symptoms. [Walter: 2023] Often, symptoms reported by the child may be combined with those reported by caregivers to arrive at a diagnosis. School dysfunction may be a strong indicator of the need for evaluation.
The prevalence of depression in adolescence is 11.0% in the United States. [Miller: 2021] The sex ratio changes as the prevalence in girls increases relative to boys resulting in a 2:1 female-to-male ratio that persists until late middle age. Pubertal hormonal and physiologic changes undoubtedly play a role, but research has not yet defined causal factors. [Angold: 2006] Diagnosis is by DSM-5-TR criteria and often can be made by an interview with the adolescent alone. It is strongly recommended to interview the adolescent and their caregivers; school dysfunction, social withdrawal, changes in friends, and new onset of arguing or defiant behavior at home may be clues to underlying depression.
Diagnostic Criteria and Classifications
Screening & Diagnostic Testing
- Beck Depression Inventory-II - ages 13 and older (available for a fee)
-
Patient Health Questionnaire Modified for Adolescents (PHQ-A) (
228 KB) - ages 11 to 17 (free)
-
Center for Epidemiological Studies Depression Scale for Children (CES-DC) (
37 KB) - ages 12 to 18 (free)
-
Center for Epidemiologic Studies Depression Scale Revised (CESD-R-20) (
262 KB) - ages 14 and older (free)
- Pediatric Symptom Checklist - ages 4-17 (free)
- Mood and Feelings Questionnaire – ages 6-19 (free)
- Strengths and Difficulties Questionnaire (SDQ) – ages 2-17 (free) - Useful to assess problematic behaviors that can be indicative of a diagnosis such as depression. [Mieloo: 2012]

Screening Family Members
Parental depression increases the risk of mood and behavior problems in children.
The USPSTF recommends screening for depression in the general adult
population, including pregnant and postpartum people. [Siu: 2016] It may be appropriate for referral to the parents’ primary
care clinician for screening or utilization of the Edinburgh Postnatal Depression Scale (Spanish) ( 54 KB). The American
Academy of Pediatrics (AAP) recommends screening all mothers for maternal
depression at well-child visits until the child is 6 months of age.
Postpartum Depression Screening provides free screens.
Although no formal diagnostic criteria for paternal postpartum
depression exist, providers should be aware that paternal depression also
adversely affects a child’s mental health and family functioning and
consider asking fathers about depression during well-child visits.
[Walsh: 2020] There is currently no specific
screening tool for paternal postpartum depression. Whereas women may present
more frequently with sadness as a cardinal symptom of depression, men may be
more likely to present with irritability and/or alcohol or substance use.
[Kim: 2007] Screen siblings in the pediatric
setting using the Center for Epidemiological Studies Depression Scale for Children (CES-DC) ( 37 KB) or other depression screens if appropriate.
Labs
A thorough history with a complete review of systems (ROS) and a physical exam may indicate the need for further laboratory testing. Studies in adults have shown little to no value in routine screening laboratory tests for psychiatric admission without indications of abnormal physical exam or history. [Zwank: 2020] In evaluating a depressive disorder, consider including tests such as TSH to screen for hypothyroidism, vitamin D to test for vitamin D deficiency, and urine drug screen to screen for substance use, which may complicate or cause depression. A urine pregnancy test should be performed for anyone with a uterus to consider pregnancy in treatment decisions.
Other
Although depression has a genetic component, no genetic tests are available to aid in diagnosing depression. Microarray analysis of cytochrome P450 enzyme gene subtypes, which can identify differences in the metabolism of antidepressants, is available, but studies to guide clinical use in youth are lacking. Routine use of imaging or EEG in the clinical evaluation of depressive disorders is not recommended. [Luby: 2016]
Genetics & Inheritance
Prevalence
Differential Diagnosis
Co-occurring Conditions
Prognosis
If untreated, a major depressive episode may diminish within 6-12 months from symptom onset - although depression can last years. Several studies have shown that treatment helps shorten the duration of symptoms and leads to improvement. [Walkup: 2017] Up to 70% of affected youths experience recurrence of major depression within five years of an episode. [Birmaher: 2007] The likelihood of subsequent recurrence increases with each episode. The outcomes and course of depression may differ significantly among individuals due to poverty, racism, and marginalization. Children and adolescents often recover from an initial depressive episode quicker, have a higher recurrence rate, and are more susceptible to switching to a bipolar disorder than adults. [Mullen: 2018]
Treatment & Management
Depression is generally episodic, with episodes lasting months to years without treatment and a high risk of recurrence. Most episodes are 6-12 months in duration, so it is recommended that treatment be continued for at least 6-12 months from symptom improvement. Medication and psychotherapy are primary treatments for children and adolescents with depressive disorders. This section provides an evidence-based overview of widely used treatments.
Mental Health / Behavior
Interim History
When assessing youth with depressive symptoms, it is essential to interview the patient separately from the parents or caregivers for at least a portion of the visit. The time spent alone with the patient depends on factors such as age, developmental level, and patient comfort level. Often, it is uncomfortable for the patient to discuss the symptoms or related life stressors in the presence of caregivers. That said, it is also essential to speak to caregivers and other sources of collateral information about signs, symptoms, current level of functioning, and history to obtain a well-rounded assessment.
Asking about depressive symptoms is the first step in ongoing assessment. A stepwise approach may help save time:
- Ask if the patient has, over the past month, frequently felt depressed, hopeless, sad, or irritable or has felt less interest in or enjoyment of usual activities. Depression and diminished interest (aka anhedonia) are cardinal symptoms of depression – one or the other must be present for diagnosis.
- Positive replies should prompt further questioning.
The diagnosis of major depression in children and adolescents
outlined in the DSM-5-TR [American: 2022]
requires 5 total symptoms; one of the symptoms must be either
depressed or irritable mood, or anhedonia. Additional symptoms
include:
- Changes in sleep
- Feelings of guilt or worthlessness
- Low energy
- Poor concentration
- Appetite or weight change
- Psychomotor slowing or agitation
- Suicidal thoughts or behaviors
- See the SIGECAPS mnemonic for depressive symptoms in Key Points above. Gather information from both the child/adolescent and a guardian. Most child/adolescent mental health professionals agree that combining symptoms from these separate reports is sufficient for a clinical diagnosis of depression. Symptoms must cause significant distress or dysfunction to meet criteria – ask about the impact on school, home, and social areas/activities. Because children may not report symptoms clearly, assessment of changes in behavior or function may provide the best clues.
The use of a validated screening tool is up to the clinician; see Screening above. A screening tool may be administered before a visit to eliminate or reduce the need for the questions outlined in 1 and 2. If depression concerns are uncovered during the routine visit, consider scheduling another visit within a week to more thoroughly address depression if it is safe to do so, and after providing information about available crisis resources to the patient and family. A screening tool could be administered in the interim. If a patient expresses Suicidality & Self-Harm, clinicians must take measures immediately to ensure the child’s or adolescent’s safety.
Treatment Approaches
Treatment approaches vary based on age:
- Infants - Medication and psychotherapy have not been studied in this age group. A nurturing home environment and treatment of depression in affected caregivers may help reduce rates of depression in infants at high familial risk. [American: 2020]
- Preschoolers - Psychotherapeutic and parenting/behavioral interventions are the treatment options most commonly used. Medication is not recommended as first-line treatment in this age group and should be referred to a psychiatrist if medication is considered due to the severity of the case; please see Monitoring treatment efficacy below for more information about referrals.
- School-Age Children - There are positive research findings for using medications and cognitive behavioral therapy (CBT) in this age group.
- Adolescents - There are positive research findings in this age group for the use of medications, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and electroconvulsive therapy (ECT).
Treatment should be individualized with the priorities of the patient and family considered. Treatment plans should be discussed with patients and their parents/guardians with adequate information to enable them to make an informed decision. Specific details of informed consent for treatment vary among states. The informed consent process includes four important elements agreed upon by many experts. This includes decision-making capacity, adequate disclosure of information for the decision-maker to make an informed decision, confirming the decision-maker’s understanding of information, and understanding that their decision for treatment should be freely authorized. [Walter: 2023] Treatment with psychotherapy and medication is generally advised for moderate to severe depression. Some of the best evidence has pointed to an advantage of medication over therapy alone. [March: 2004] However, treatment with medication may not be the first choice for all, and psychotherapy alone may be considered for patients with mild to moderate depression.
Patients expressing active suicidal ideation or who have recently made a suicide attempt should be referred for inpatient psychiatric hospitalization.
Monitoring treatment efficacy
Most of the screening tools listed in this module can also be used to monitor treatment efficacy. A psychiatric referral is necessary for patients with suspected bipolar disorder or depression with psychotic features. Due to chronic shortages in the US, psychiatrists often only see those patients with severe mental illness or complicating biological, psychological, or social factors. The intervention of a child and adolescent psychiatrist should be considered based on provider experience and comfort level and for patients who:
- Require more than 2 psychotropic medications to control symptoms or has had only partial response to medication
- Have no improvement after 6-8 weeks of medication or therapy
- Require psychiatric hospitalization
- Have parents with significant emotional impairment or substance use issues
- Have complex psychosocial issues (e.g., history of abuse/neglect, legal problems, poor parental support/supervision, family conflict)
- Have a family history suggesting adverse reactions to therapy (e.g., planned antidepressant treatment in a patient with a family history of bipolar disorder)
- Are young (<5 years old) with emotional and behavioral disturbances that are severe or prolonged
- Have chronic medical illness with behaviors that interfere with the treatment of that illness
Medications
- Start at low doses and titrate up as tolerated. A trial at an adequate dose should last 2-4 weeks before any further dose increase because it may take that long to see any benefit. If there is no beneficial effect after 2-4 weeks, and the patient is tolerating the medication, the dose may be increased.
- Total trial time should be at least 6-8 weeks. A medication trial should not be considered a failure until the maximum tolerated dose has been used for this long without improvement.
- Patients should have frequent follow-ups, preferably weekly, until a dose is stable and medication is tolerated.
- Antidepressants work best when taken at the same time daily, which helps adherence and minimizes the risk of discontinuation syndrome (especially agents with a shorter half-life).
- Most antidepressants with once-a-day dosing can be taken in the morning or evening based on patient preference and observed side effects. • Family history of response to a particular medication may be an approximate guide for medication selection.
- The FDA approval of fluoxetine and escitalopram may make those medications appealing choices for clinicians; however, clinical judgment may lead to the “off-label” use of other medications.
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the best-studied antidepressant medications for children and adolescents. They also have significant benefits for anxiety disorders, including generalized anxiety disorder, panic disorder, and OCD. The effects of SSRIs on anxiety reduction are important, given that anxiety disorders are commonly comorbid with depression.
SSRIs increase levels of serotonin activity by decreasing the presynaptic reuptake of serotonin. SSRIs have a minimal effect on other neurotransmitters, such as dopamine and norepinephrine. SSRI side effects are usually mild and often self-resolve in 1-2 weeks. Common side effects include headaches, GI upset, somnolence, agitation, and sexual side effects (e.g., decreased libido, anorgasmia).
SSRIs are considered first-line pharmacological treatment.
Fluoxetine has the most positive data from controlled trials in children and adolescents, with three trials demonstrating significant differences from placebo. [March: 2004] [Emslie: 2002] It has a longer half-life than most other SSRIs (1-4 days), and an active metabolite, norfluoxetine, which has an even longer half-life (7-15 days). The half-life can be a useful pharmacokinetic feature since it is more forgiving than other SSRIs when patients miss doses. However, if a patient has a negative response to fluoxetine, the long half-life can extend the duration of the adverse reaction.
- FDA approved for use in children eight years and older with MDD and those seven years and older with obsessive-compulsive disorder.
- Available as brand name (e.g., Prozac) and generic in several formulations, including 10 mg, 20 mg, 40 mg, and 60 mg tablets; 10 mg, 20 mg, and 40 mg capsules; 90 mg delayed release (weekly) capsules; 20 mg/5 ml solution
- Starting dose for adolescents: 10 to 20mg once daily, initial target dose 20mg once daily, dose range 10mg-60mg once daily
Escitalopram is the S-isomer of citalopram. Escitalopram has had 3 controlled trials. One controlled trial in adolescents aged 12 to 17 years had positive results. [Emslie: 2009] Two other controlled trials [Wagner: 2006] and unpublished data (Forest Laboratories) did not significantly differ from placebo. Of note, a post-hoc analysis of the data from the published negative study showed a significant difference from placebo for the adolescent age group.
- FDA-approved treatment of depression in adolescents aged 12 to 17 years (based on the strength of the positive study and data from a study of citalopram)
- Available as brand name (e.g., Lexapro) and generic in 5 mg, 10 mg, 20 mg tablets and 5 mg/5 ml oral solution.
- Starting dose for adolescents: 5mg to 10mg once daily, initial target dose 10mg once daily, dose range 10mg to 30mg once daily.
Sertraline has 1 positive trial (2 studies, which were combined by study design); however, the significance of the trial results was lessened by a very high placebo response rate (53%). [Wagner: 2003] High placebo response rates are characteristic of all existing trials of antidepressants in children and adolescents.
- FDA approved for use in children 6 years and older with MDD.
- Available as brand name (e.g., Zoloft) and generic in several formulations, including 25 mg, 50 mg, 100 mg tablets, and 20 mg/ml oral concentrate.
- Starting dose for adolescents: 12.5mg to 25mg once daily, initial target dose 50mg once daily, dose range 25mg to 200mg once daily.
Paroxetine has 1 trial with mixed results [Keller: 2001] and 1 negative trial [Emslie: 2006], so the evidence for efficacy is equivocal. Paroxetine also appears to be less well tolerated in children and adolescents and has significant discontinuation symptoms (possibly due to the short half-life of 20 hours). Paroxetine had worse suicidal ideation and treatment withdrawal in children and adolescents with MDD when compared to placebo. [Walter: 2023]
- Not FDA approved for use in children; other SSRIs may be better for children and adolescents who may be more prone to missing doses and therefore be at higher risk of discontinuation syndrome.
Citalopram has had 2 controlled trials. One had positive results [Wagner: 2006]; the other did not show a significant difference from the placebo (unpublished). The non-significant study included inpatients and a high dropout rate, which may have made the results difficult to interpret. Citalopram has also been studied in pediatric patients with functional abdominal pain, with a trend toward efficacy. [Roohafza: 2014]
- Not FDA-approved for use in children. In August 2011, the FDA issued a Drug Safety Communication warning of the potential for QT prolongation and Torsades de Pointes in patients taking citalopram at doses higher than 40mg daily, and that citalopram should no longer be used at such doses. The FDA also discouraged citalopram in patients with cardiac conditions predisposing to arrhythmia, including congenital long QT syndrome.
- Available as brand name (e.g., Celexa) and generic in 10 mg, 20 mg, and 40 mg tablets and 10 mg/5 ml oral solution
- Starting dose for adolescents: 10mg once daily; initial target dose 10mg to 20mg once daily; dose range 10mg to 40mg once daily.
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
SNRIs increase levels of serotonin and norepinephrine activity by decreasing the presynaptic reuptake of serotonin and norepinephrine. SNRI side effects are usually mild and often self-resolve in 1-2 weeks. Common side effects include headaches, dry mouth, GI upset, somnolence, insomnia, and sexual side effects (e.g., decreased libido, anorgasmia).
Venlafaxine (Effexor) has effects similar to SSRIs. In fact, at lower doses (<225 mg daily), the norepinephrine reuptake action is not present, effectively making venlafaxine an SSRI at these doses. There have been few studies on its use in children and adolescents. Venlafaxine was studied in a large RCT involving patients who continued to have depression despite adequate treatment with one SSRI and was not significantly better in that context than a second SSRI; there was no placebo arm. [Brent: 2008] One unpublished study and 1 small, randomized controlled trial did not show significant benefits. [Boylan: 2007] Pooled results of these 2 studies showed only a small benefit for adolescents. A high rate of placebo response may have hampered studies. Venlafaxine also has significant discontinuation symptoms that may begin within a few hours of a missed dose.
- Not FDA approved for use in children and adolescents
- Available as brand name (e.g., Effexor or Effexor XR) and generic in 25 mg, 37.5 mg, 50 mg, 75 mg, and 100 mg tablets.
- “Off label” starting dose for adolescents: 37.5-75 mg/day with maintenance dose of 150-300 mg/day
Desvenlafaxine SR (Pristiq) is a form of the active metabolite of venlafaxine. Desvenlafaxine SR has had 1 controlled trial. [Weihs: 2018] This trial compared desvenlafaxine SR weight-based dosing to fluoxetine and placebo and was non-significant due to improvement in all study arms.
- Not FDA approved for use in children and adolescents
- Starting dose in adults: 50 mg/day
Duloxetine (Cymbalta) has had 2 controlled trials. [Emslie: 2014] [Atkinson: 2014] Both studies compared duloxetine to fluoxetine (as a standard treatment) and placebo. Both studies showed no significant differences between treatments due to improvement in depression in all study arms (duloxetine at fixed and flexible doses of up to 120 mg daily, fluoxetine up to 40 mg daily, and placebo).
- Not FDA approved for depression in children and adolescents, but is FDA-approved for Generalized Anxiety Disorder (GAD) in ages 7-17
- Starting dose for GAD in children and adolescents : 30 mg/day
Levomilnacipran (Fetzima) is the newest SNRI on the market, approved by the FDA for treating depression in adults in July 2013. A controlled study was completed in 2020 for treatment with levomilnacipran in adolescents with MDD, and interpretation of the results is in progress.
- Not FDA approved for use in children and adolescents
- Starting dose in adults: 20 mg/day
Atypical Antidepressants
Atypical antidepressants are antidepressants that act differently than any of the other four classes of antidepressants. The mechanism of action of each of these is unique to the specific medications. Common side effects include dry mouth, dizziness, or lightheadedness. Other possible side effects differ between the atypical antidepressants.
Bupropion has no controlled studies for depression in children and adolescents. One open study of bupropion in children with depression and comorbid ADHD has positive results. [Daviss: 2001] Bupropion is used in adults for depression and smoking cessation. Unlike SSRIs, bupropion has little positive effect on anxiety (and can cause anxiety in some). It may be useful in patients with bipolar disorder and depression as it is less likely than other antidepressants to induce mania. There is a small risk of generalized seizures with bupropion, higher at doses >300 mg daily. Due to the increased risk of seizures, bupropion is contraindicated in patients with an active eating disorder.
- Not FDA-approved for use in children.
- Available as brand names (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban) and generic in 75 mg and 100 mg tablets; 100 mg, 150 mg, and 200 mg extended release (12-hour) tablets; 174 mg, 348 mg, and 522 mg extended release (24 hours) tablets (as hydrobromide); and 150 mg, 300 mg, and 450 mg extended release (24 hours) tablets (as hydrochloride)
- Starting doses in adolescents: bupropion SR 75 mg twice daily, initial target dose 100 mg twice daily, dose range 75 mg to 150 mg twice daily; bupropion XL (Wellbutrin XL) starting dose 150 mg once daily, initial target dose 150 mg to 300 mg once daily, dose range 150 mg to 450 mg once daily.
Mirtazapine (Remeron) has multiple actions at the CNS receptor level that may contribute to the antidepressant effect. There have been 2 unpublished trials of mirtazapine for depression in children and adolescents. Neither trial demonstrated a significant difference from the placebo. As with venlafaxine, this lack of apparent effect may be due to high placebo response rates. Mirtazapine has a sedating effect that paradoxically occurs at lower doses and is sometimes used at night to treat comorbid insomnia.
- Not FDA approved for use in children and adolescents
- “Off label” use starting dose: 7.5 mg up to 30 mg daily. Lower doses preferred when additionally targeting insomnia.
Vortioxetine (Trintellix) was approved by FDA for treating depression in adults in September 2013. It increases circulating serotonin levels. A controlled study on adolescent MDD was published in 2022 with negative results showing no difference between combined doses of vortioxetine and placebo. Vortioxetine used in adolescents showed a safety profile similar to that in adults. [Findling: 2022]
- Not FDA approved for use in children and adolescents
- Starting dose in adults: 10 mg/day
Vilazodone (Viibryd) was approved by FDA for treating depression in adults in January 2011. A controlled study in pediatric MDD focused on adverse effects was completed in Clinical Trials Vilazodone in Adolescents (clinicaltrials.com).
- Not FDA approved for use in children and adolescents
- Starting dose in adults: 10 mg/day with food
Tricyclic Antidepressants (TCAs)
TCAs have been available for many years but have been eclipsed by SSRIs, SNRIs, and other antidepressants for primary treatment of depression, primarily due to other agents having fewer side effects and less toxicity. TCAs inhibit the reuptake of serotonin and norepinephrine, leading to increased concentration of these neurotransmitters. In addition, TCAs also block postsynaptic histamine, alpha-adrenergic, and muscarinic-acetylcholine receptors. TCAs have several adverse side effects, including common side effects of constipation, dizziness, and dry mouth. Toxicity and overdose can result in cardiac arrhythmias, seizures, coma, and death. [Moraczewski: 2022] Pediatric clinicians need to know that multiple trials of TCAs have failed to show significant benefits compared to placebo for treating depression in children and adolescents. A Cochrane review from 2013 supported the same conclusion. [Hazell: 2013]
Monoamine oxidase inhibitors (MAOIs) function by inhibiting the monoamine oxidase enzyme resulting in accumulation of serotonin, norepinephrine, and dopamine in synaptic clefts. MAOIs' side effect profile is severe. MAOI cross-reacts with tyramine, resulting in hypertensive crisis, and dietary restrictions are recommended for doses used to treat depression. A frequent adverse side effect of MAOIs includes dizziness in almost half of users. [Sabri: 2022]
Over-the-Counter and Herbal
St. John’s Wort (hypericum), an herbal remedy sometimes recommended for depression, induces cytochrome P450 3A4, which can result in lowered blood levels of other drugs that are metabolized by that enzyme (e.g., macrolide antibiotics, azole antifungals, benzodiazepines, calcium channel blockers, and calcineurin inhibitors, like cyclosporin and tacrolimus). St. John’s Wort also interacts with other antidepressants, such as SSRIs (e.g., fluoxetine, sertraline), SNRIs (e.g., venlafaxine), and MAOIs (e.g., selegiline). If taken along with these antidepressants, it may increase the risk of serotonin syndrome, a severe and potentially fatal drug reaction.
Saffron is another herbal remedy being used for treatment of depression. Further studies are required to determine if any interactions exist with other antidepressants.
Nutritional supplements used to treat depression include S-adenosylmethionine (SAMe), 5-hydroxytryptophan (5-HTP), eicosapentaenoic acid (EPA), zinc, and folate. 5-HTP is the only serotonergic agent of these and may increase the risk of serotonin syndrome. [Sarris: 2019]
Light therapy is a nonpharmacological treatment that exposes individuals to artificial light, typically at a “dose” of 10,000 lux for 30-60 minutes in the morning. [Campbell: 2017] [Nussbaumer-Streit: 2019]The evidence for light therapy as preventive treatment for Seasonal affective disorder (SAD) is limited. Ultimately the decision for or against treatment should be based on patient preferences. is identified as major depressive disorder with a seasonal pattern. Symptoms commonly occur during the fall or winter months and usually improve in the spring.
Safety Considerations
Serotonin Syndrome
Combining agents that increase serotonin levels with any antidepressant, including but not limited to SNRIs, TCAs, and other SSRIs, increases serotonin syndrome risk. Serotonin syndrome is an adverse reaction and a medical emergency. Symptoms of serotonin syndrome include fever, confusion, and tremor/rigidity. Specific medication interactions, such as SSRIs with triptan medications or MAOIs, increase risk. All patients should be questioned about their herbal, dietary, and over-the-counter medicines and supplements. If serotonin syndrome is suspected, the offending agent should be immediately discontinued, and the patient should be referred to an emergency room for monitoring and possible hospital admission if severe.
Antidepressants and Suicidal Adverse Events (SAEs)
The use of antidepressant medication in children became a more controversial topic since the British Medications and Healthcare Regulatory Agency banned all antidepressant use except for fluoxetine in patients <18 years of age in the United Kingdom in 2003. This ban was instituted due to concerns about potential suicidal thoughts or behavior in patients taking antidepressant medication. Subsequent evaluation by the US FDA led to a black box warning in 2004 for all antidepressants stating that they may increase the risk of suicidal thinking and behavior in children and adolescents with major depressive disorder and other psychiatric disorders. The FDA added a similar warning in 2007 for young adults aged 18-24.
The FDA did not institute a ban on use of antidepressants in children and adolescents, nor did the agency revoke the approval of fluoxetine for treating depression in patients aged 7-18. The warning reflects an increased risk of suicidal thoughts or behaviors only, not an increased risk of completing suicide: No one in the studies evaluated by the FDA completed suicide. The risk of suicidal thoughts or behaviors for those taking active medication was 3.9%, while the placebo group was 1.8%. [Hammad: 2006]
An independent review of available data by the American Medical Association indicated that “a causal role for antidepressants in increasing suicides in children and adolescents has not been established. Concerns that antidepressants potentiate suicidal or self-injurious behavior need to be balanced by the clear risk of suicide in children and adolescents with untreated depression.” [Jane: 2016] Another analysis of all available antidepressant RCTS in youth suggests that antidepressants have benefits that may outweigh these risks. [Bridge: 2007] There is also data demonstrating a correlation between higher rates of SSRI prescriptions and reduced child and adolescent suicide rates. [Gibbons: 2006]
Given concerns for SAEs, rational prescribing practices include educating patients and parents on the safety concerns around antidepressant use. Patients who are started on antidepressant medication should be observed closely for clinical worsening, suicidal thoughts, or unusual changes in behavior. Families and caregivers should be advised to monitor the patient closely and to communicate with the prescribing physician. Follow-up should occur within 1 week after a patient is newly started on an antidepressant.
Antidepressant Discontinuation Syndrome
Discontinuation symptoms can appear 24 to 48 hours after abruptly stopping an antidepressant and occur more commonly with agents with a shorter half-life, such as paroxetine and venlafaxine. It can be challenging to differentiate between recurrence of a depressive episode and antidepressant discontinuation syndrome. Serotonergic discontinuation symptoms include sensations of paresthesias (some patients may describe feeling “brain zaps”), flu-like symptoms, nausea, irritability, insomnia, tiredness, and headache. It is strongly recommended to gradually taper off medications to avoid discontinuation symptoms. [American: 2009] Abrupt discontinuation of tricyclic antidepressants may result in other symptoms.
Psychotherapy
The other primary treatment modality is psychotherapy, which refers to any psychology-based treatment directed by a trained mental health professional and delivered by means of communication or behavioral techniques. Psychotherapy is often referred to as ”counseling“ or “talk therapy.” Several types of psychotherapy exist, but the only two with significant research evidence for efficacy in treating depressive disorders in children and adolescents recommended by the American Psychological Association for initial treatment are cognitive behavior therapy (CBT) and interpersonal therapy (IPT).
Cognitive Behavioral Therapy (CBT)
CBT is based on a theory that individuals with depression have negative assumptions about themselves, the world, and the future that are learned through early experience and interact with later life stress to distort the individual’s perception of their situation. These assumptions and resulting distortions lead the depressed individual to make faulty assessments of current life situations, thus supporting depression. Based on these assumptions, the individual may also make decisions that further support depression (e.g., choosing to isolate oneself and then feeling lonelier and more hopeless).
CBT formats vary, but most CBT programs involve a highly structured process guided by written manuals with specific steps and instructions for each step or session. The process involves two primary goals:
- Identifying faulty assumptions (cognitive distortions) and correcting them gradually
- Behavioral interventions designed to minimize symptoms of depression
Although some studies have had conflicting results, CBT has been shown to affect depression positively. Two studies compared a form of CBT with placebo, fluoxetine, and a fluoxetine plus CBT condition, and CBT failed to separate from the placebo condition. [March: 2004] [Freeman: 2018]
The TADS result raises the issue of severity of depression and comorbidity. The TADS sample had a high degree of severity of depression. Other studies that failed to show a significant effect for CBT also had highly severe samples. This finding may support the use of CBT for mild to moderate depression. Certain comorbidities, such as anxiety disorders, may predict better response, while others, such as conduct disorder, may predict poor response to CBT.
Another issue is the form of CBT used. Many positive studies of CBT used very specific forms (e.g., Coping with Depression for Adolescents - a group therapy that has been used in almost half of all published studies of CBT). The TADS study used a novel form that had not been assessed in any other setting before the TADS study. This finding may imply that CBT efficacy depends upon using a specific format.
Interpersonal Therapy (IPT)
IPT is based on the concept that depression occurs in the context of interpersonal relationships, and both the development of depression and recovery from depression are affected by these relationships. IPT addresses these effects by identifying problem areas (typically grief and loss; disputes or conflicts with family, friends, or teachers; life transitions; or social deficits). Therapy then focuses on improving communication and problem-solving skills to help resolve interpersonal problems and thus, improve mood.
IPT has been well studied and validated as an effective treatment for depression in adults. IPT has also been studied in two randomized trials in adolescents with positive results. There is a manualized IPT program (IPT-A) adapted specifically for use with adolescents. IPT shows promise as an evidence-based psychotherapeutic treatment for mild to moderate depression in adolescents. Some limitations of the use of IPT include that it has not been as well studied as CBT, and not as many therapists are trained in the use of IPT.
Most therapists do not adhere to a single therapeutic theory or method. This approach must be considered when the desire to follow evidence-based methods is applied in the real-world treatment of children and adolescents with depression. “Eclectic” or individualized therapy programs may be effective but cannot be readily evaluated in a controlled trial. Whatever type of therapy is chosen, the role of the referring physician can be invaluable in providing regular follow-up and symptom monitoring to help evaluate progress. The “fit” between a patient and therapist can also improve treatment adherence and response, regardless of modality.
Sleep
Nutrition
Physical Activity
Services & Referrals
General Counseling Services
(see NM providers
[10])
This category includes all types of counselors/counseling for
children. Once on the page, the search can be narrowed by city or using the Search
within this Category field.
Psychiatry/Medication Management
(see NM providers
[3])
Can be very helpful in guiding and/or managing pharmacologic therapy,
particularly for patients who do not respond promptly or well to standard
medications.
Social Workers
(see NM providers
[0])
Social workers can help families identify family issues and improve
communication skills and relationships. Social workers can help with crisis
intervention and utilizing resources.
ICD-10 Coding
Coding for Developmental & Mental Health Screening has further coding options.
- F32.x, Major depressive disorder, single episode
- F33.xx, Major depressive disorder, recurrent episode
- F32.89, Other specified depressive disorder
- F32.9, Unspecified depressive disorder
- F34.1, Persistent depressive disorder (formerly dysthymia)
- F34.81, Disruptive mood dysregulation disorder
- F43.21, Adjustment disorder with depressed mood
- F43.23, Adjustment disorder with mixed anxious and depressed mood
- F32.81, Premenstrual dysphoric disorder
For major depressive disorder, a 4th digit, indicated by x, is required as indicated by number and severity of symptoms. For recurrent episodes, a 5th digit may be required to indicate severity/status. For coding details, see ICD-10 for Depressive/Mood Disorders (icd10data.com), ICD-10 for Adjustment Disorders (icd10data.com), or the Diagnostic and Statistical Manual of Mental Disorders [American: 2022].
Resources
Information & Support
Related Portal Content
- Suicidality & Self-Harm
- Anxiety Disorders
- Attention-Deficit/Hyperactivity Disorder (ADHD) & Mood Disorders
- Mental Health Screening for Children & Teens
- Postpartum Depression Screening
- Screening for Eating Disorders
- Depression (FAQ)
- Anxiety Disorders (FAQ)
Medical information in one place with fillable templates to help both families and providers. Choose only the pages needed to keep track of the current health care summary, care team, care plan, and health coverage.
For Professionals
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research,
and getting help for depression; American Academy of Child & Adolescent Psychiatry.
Resources for Primary Care (AACAP)
A resource center for clinicians treating substance use disorders and mental health issues. Includes practice parameters,
a guide for integrating mental health care into the medical home, and information about policy and advocacy; American Academy
of Child & Adolescent Psychiatry.
Zero to Three
A national nonprofit organization that promotes the health and development of infants and toddlers. Provides information and
resources for parents and professionals about the development, learning, behavior, and well-being of infants and toddlers.
Includes real-life video examples, articles, and FAQs.
Resources for Clinicians for the Treatment of Depression (APA)
Treatment manuals, continuing education and other courses, training and professional organizations, case examples, and more;
American Psychological Association.
Patient Education
Family Resources (AACAP)
Family education for disorders that include anxiety, autism, depression, conduct disorder, oppositional defiant disorder,
and more, Includes facts, videos, and a psychiatrist finder tool; American Academy of Child & Adolescent Psychiatry.
Tools
Beck Depression Inventory-II
A self-administered, 21-item, 10-minute screen for depression for ages 13 years and older; available in Spanish or English
for purchase.
Center for Epidemiologic Studies - Depression Scale (CES-D) ( 171 KB)
A free, self-administered, 20-item, 10-minute screen for depression for ages 14 years and older.
Center for Epidemiologic Studies Depression Scale Revised (CESD-R-20) ( 262 KB)
Self-report measure of depression with 8 different subscales.
Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders.
Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.
Preschool Feelings Checklist (PFC) ( 22 KB)
A 16-item parent report measure of depressive symptoms in young children.
Depression: Parents' Medication Guide (AACAP and APA) ( 1.2 MB)
Causes and symptoms of depression, suicide prevention, medications, psychosocial treatment, unproven treatments, and helping
the depressed child; American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association.
Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes
a variety of resources, checklists, intake and assessment forms, and patient education materials.
Services for Patients & Families in New Mexico (NM)
Service Categories | # of providers* in: | NM | NW | Other states (3) (show) | | NV | RI | UT |
---|---|---|---|---|---|---|---|---|
General Counseling Services | 10 | 1 | 205 | 30 | 306 | |||
Psychiatry/Medication Management | 3 | 38 | 80 | 53 | ||||
Social Workers | 5 | 12 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Studies
Depression in Children and Adolescents (ClinicalTrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.
Helpful Articles
PubMed search for depression in children and adolescents, last two years
Cheung AH, Kozloff N, Sacks D.
Pediatric depression: an evidence-based update on treatment interventions.
Curr Psychiatry Rep.
2013;15(8):381.
PubMed abstract / Full Text
Maalouf FT, Brent DA.
Child and adolescent depression intervention overview: what works, for whom and how well?.
Child Adolesc Psychiatr Clin N Am.
2012;21(2):299-312, viii.
PubMed abstract
LeMoult J, Humphreys KL, Tracy A, Hoffmeister JA, Ip E, Gotlib IH.
Meta-analysis: Exposure to Early Life Stress and Risk for Depression in Childhood and Adolescence.
J Am Acad Child Adolesc Psychiatry.
2020;59(7):842-855.
PubMed abstract
Mendelson T, Tandon SD.
Prevention of Depression in Childhood and Adolescence.
Child Adolesc Psychiatr Clin N Am.
2016;25(2):201-18.
PubMed abstract
Wren FJ, Foy JM, Ibeziako PI.
Primary care management of child & adolescent depressive disorders.
Child Adolesc Psychiatr Clin N Am.
2012;21(2):401-19, ix-x.
PubMed abstract
Authors & Reviewers
Author: | Alexa Gathman Ries |
Senior Author: | Mary Steinmann, MD, FAAP, FAPA |
2018: update: Thomas G. Conover, MDA; Jonathan D. Birnkrant, MDR |
2013: first version: Thomas G. Conover, MDA |
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Evidence-based information about the appropriate and safe use of psychotropic medications in children and adolescents with
psychiatric disorders; emphasizes the best practice principles that underlie medication prescribing.
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).
Fifth ed. Arlington, VA: American Psychiatric Association Publishing;
2022.
978-0-89042-579-4 https://psychiatry.org/psychiatrists/practice/dsm
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
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978-0-89042-554-1
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A Child’s Home Environment Can Impact the Risk of Developing Depression.
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A double-blind efficacy and safety study of duloxetine flexible dosing in children and adolescents with major depressive disorder.
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The most recent practice parameter on the diagnosis and treatment of depressive disorders in children and adolescents. Our
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pediatric practice.
Bitsko RH, Holbrook JR, Ghandour RM, Blumberg SJ, Visser SN, Perou R, Walkup JT.
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Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant
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JAMA.
2008;299(8):901-13.
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Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA.
Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis
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J Am Acad Child Adolesc Psychiatry.
2016;55(7):580-90.
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Cheung AH, Kozloff N, Sacks D.
Pediatric depression: an evidence-based update on treatment interventions.
Curr Psychiatry Rep.
2013;15(8):381.
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Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.
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Emslie GJ, Heiligenstein JH, Wagner KD, Hoog SL, Ernest DE, Brown E, Nilsson M, Jacobson JG.
Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial.
J Am Acad Child Adolesc Psychiatry.
2002;41(10):1205-15.
PubMed abstract
Emslie GJ, Prakash A, Zhang Q, Pangallo BA, Bangs ME, March JS.
A double-blind efficacy and safety study of duloxetine fixed doses in children and adolescents with major depressive disorder.
J Child Adolesc Psychopharmacol.
2014;24(4):170-9.
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2006;45(6):709-719.
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Neuron.
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Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating, Improving, and Transporting
What Works.
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Tricyclic drugs for depression in children and adolescents.
Cochrane Database Syst Rev.
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Integrated Treatment of Adolescents with Co-occurring Depression and Substance Use Disorder.
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2019;28(3):461-472.
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