Patients with active suicidal ideation, which involves the presence of a specific plan or intent to take one's life, warrant emergent evaluation. This may include evaluation at the hospital or by a crisis intervention team.
Diagnosis Overview:
Pediatric depressive disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) encompasses several different diagnostic concepts, including major depressive disorder (MDD), persistent depressive disorder (dysthymia) (PDD), disruptive mood dysregulation disorder (DMDD), and depressive disorder not otherwise specified (NOS).
Depressive disorders are common in older children and adolescents and are a leading cause of morbidity, with suicide being the third-most common cause of death in adolescents. In 2021, 15%-20% of adolescents in the United States met criteria for MDD, with females more commonly being affected than males.
The causes of depression are complex and multifactorial, with risk factors including adverse environmental circumstances, psychosocial stressors, socioeconomic stressors, genetics / family history, gender identity issues / issues of sexual orientation, substance abuse, comorbid medical problems, sleep disturbances, and coexisting psychological diagnosis. Patients are also higher risk if there is a family history of depression or they have previously been diagnosed with depression. Annual screening for depression with a validated screen tool is recommended for all children ages 12-18 years.
Depression rates rose significantly during the COVID-19 global pandemic and continue to remain high.
Depressive symptoms in the pediatric population include a variety of symptoms that vary by age. Prepubertal children and adolescents often present with irritability, behavioral problems, restrictive affect, and somatic complaints (eg, headaches, stomachaches). Adolescents additionally may display hypersomnia / insomnia, weight gain or loss, and substance use.
DSM-5-TR criteria for MDD include 5 or more of the following symptoms (and must include depressed mood or irritability) in a 2-week period that are not accounted for by a medical diagnosis and are changes in previous functioning:
- Depressed mood / irritability
- Loss of interest or pleasure
- Weight loss, weight gain, or change in appetite
- Hypersomnia or insomnia
- Psychomotor agitation or retardation
- Excessive fatigue
- Feeling worthless / inappropriate guilt
- Decreased concentration
- Thoughts of suicide / death
DSM-5-TR criteria for PDD include 3 or more of the following symptoms (and must include depressed mood or irritability) for more days than not for a year or longer, with no more than 2 months at a time absent of the criteria:
- Depressed or irritable mood
- Change in appetite, weight gain, or weight loss
- Insomnia or hypersomnia
- Excessive fatigue
- Poor concentration
- Decreased self-esteem
- Feelings of hopelessness
