Childhood and Adolescent Depression

SH ASHI K. BH ATI A, M.D., a nd SUBH ASH C. BH ATI A, M.D., Creighton University, Department of Psychiatry, Omaha, Nebraska

Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies. (Am Fam Physician 2007;75:73-80, 83-4. Copyright 2007 American Academy of Family Physicians.)
Patient information: A handout on depression in children and adolescents, written by the authors of this article, is provided on page 83.

t any given time, up to 15 percent of children and adolescents have some symptoms of depression. Five percent of those nine to 17 years of age meet the criteria for major depressive disorder,1,2 and 3 percent of adolescents have dysthymic disorder.3 The incidence of depressive disorders markedly increases after puberty. By 14 years of age, depressive disorders are more than twice as common in girls as in boys, possibly because of differences in coping styles or hormonal changes during puberty.4 Adolescent depressive disorders often have a chronic, waxingand-waning course, and there is a two- to fourfold risk of depression persisting into adulthood.5,6 Depression impacts growth and development, school performance, and peer or family relationships, and it can be fatal. Major depressive disorder is a leading cause of youth suicidal behavior and suicide.7,8 More t han 70 percent of children and adolescents wit h depressive disorders or ot her serious mood disorders do not receive appropriate diag nosis a nd t reat ment.9 Possible

reasons for t his may be t he st igma attached to t hese disorders, an at y pical presentat ion, a lack of adequate child mental healt h t raining for healt h care professionals, an inadequate number of child psychiat rists, and inequalit ies in mental healt h care insurance. Underdiagnosis and undert reat ment are greater problems in children younger t han seven years, in par t because of t his age groups limited abilit y to communicate negat ive emot ions and t houg hts wit h language and consequent tendency toward somat izat ion. Thus, young children wit h depression may present wit h general aches and pains, headaches, or stomachaches. Addit ionally, if a parent has major depressive disorder, he or she may minimize t he child s depressive sy mptoms t hroug h a lack of awareness or an unwillingness to recognize sy mptoms t hat may be similar to his or her ow n. Risk Factors Risk factors for child and adolescent depressive disorders include biomedical and psychosocial factors (Table 1).1,3,4,6,10-15

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Childhood Depression
SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence rating A B A C C

Clinical recommendation Tri c yc li c ant i depre ss ant s s hou l d not be u s ed to treat c h il dhood or ado l e s c ent depre ssi on . Se l e c t ive s eroton i n reuptake i nh i b i tors have li m i ted evi den c e of effe c t ivene ss i n c h il dren and ado l e s c ent s and s hou l d be re s erved for treatment of s evere ma j or depre ssi on . Cogn i t ive behavi or therapy is effe c t ive for the treatment of m il d to moderate depre ssi on . Ch il dren and ado l e s c ent s tak i ng ant i depre ss ant s s hou l d be mon i tored c l o s e ly for su i c i da l thought s and behavi or. Depre ssi on s hou l d be treated for a m i n i mum of six month s.

References 18 , 40 , 41 42-44 18 , 37-39 53 29

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 13 or http:// www.aafp.org/afpsort.xml.

Approximately two thirds of children and adolescents with major depressive disorder also have another mental disorder.15 It is essential that physicians recognize and treat associated psychiatric comorbidities; the most common of these are dysthymic disorder, anxiety disorders, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and substance use disorder. Screening It is unclear whether routinely screening all children and adolescents for depression is beneficial in the primary care setting.16 Physicians who choose to screen may use the Childrens Depression Inventory (CDI), a reliable and

valid self-rating scale for boys and girls seven to 17 years of age.17-19 The CDI scale requires a first-grade reading level; it is available in long (27-item) and short (10-item) forms and in parent and teacher versions. Each item on the scale is scored from 0 to 2 according to the presence or absence of symptoms in the previous two weeks: 0 indicates symptom absence, 1 indicates mild symptoms, and 2 indicates a definite symptom. The raw score is plotted on a scoring grid and converted to a T-score. A raw score greater than 20 on the long form or greater than 7 on the short form and a T-score greater than 65 are clinically significant. Presentation Juvenile depression may manifest in different forms. As stated above, children younger than seven years may not be able to describe their internal mood state and may express their distress through vague somatic symptoms or pain. Irritable mood may be the cause of angry, hostile behavior. Impaired attention, poor concentration, and anxiety may resemble attention-deficit/hyperactivity disorder, and substance abuse may be a means of selfmedication for depression. Diagnosis Diagnosis of primary depressive mood disorders (Table 2) requires that physicians rule out depression from medical causes, such as endocrinopathies, malignancies, chronic diseases, infectious mononucleosis, anemia, and vitamin deficiency (especially folic acid),10 and from medications, such as isotretinoin (Accutane).13 If any of these causes are present, the condition is referred to as secondary depressive mood disorder or depressive mood disorder secondary to medical conditions. Lack of improvement following treatment or medication discontinuation warrants further evaluation and treatment. Major depressive disorder is t he most severe of t he depressive mood disorders. The Diagnostic and Statistical Manual of Mental Disorders, 4t h ed., criteria for
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TABLE 1

Risk Factors for Child and Adolescent Depressive Disorders

Biomedical factors Chron i c ill ne ss (e . g ., d i abete s)10 F ema l e s ex4 Hormona l c hange s duri ng puberty4 ,11 P arenta l depre ssi on or fam ily h is tory of depre ssi on1,12 Pre s en c e of s pe c i f i c s eroton i n-trans porter gene vari ant s11 U s e of c erta i n med i c at i ons (e . g ., is otret i no i n [A cc utane])13 Psychosocial factors12 Ch il dhood neg l e c t or abu s e (physi c a l , emot i ona l , or s exua l ) Genera l s tre ss ors i n c l ud i ng s o c i oe c onom i c deprivat i on s Lo ss of a l oved one , parent , or romant i c re l at i on s h i p Other factors A nxi ety d is order 6 ,14 Attent i on-def i c i t / hypera c t ivi ty, c ondu c t , or l earn i ng d is orders12 ,15 C i garette s mok i ng12 H is tory of depre ssi on 3
Information from references 1, 3, 4, 6, and 10 through 15.

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Childhood Depression

diagnosing major depressive disorder in children and adolescents are similar to t hose for adults (Table 3).20-24 If substance abuse is present, an independent diagnosis of major depression requires t he presence of depression before substance abuse or during periods of remission. Concurrent t reat ment of substance use disorder and depression is needed to improve outcomes for bot h.25 Adjustment disorder wit h depressed mood is t he most common depressive mood disorder in children and adolescents. Sy mptoms start wit hin t hree mont hs of an identifiable stressor (e.g., loss of a relationship), wit h distress in excess of what would be expected and interference wit h social, occupational, or school f unctioning. Sy mptoms should not meet criteria for anot her psychiatric disorder, are not caused by bereavement, and do not last longer t han six mont hs af ter t he stressor has stopped. Dysthymic disorder is a chronic, milder form of depression characterized by a depressed or irritable mood (indicated subjectively or described by others) present for more days than not for at least one year (as opposed to two years for adults). Two of the following additional sy mptoms also are required: changes in appetite, sleep difficult y, fatigue, low self-esteem, poor concentration or difficult y

with making decisions, and feelings of hopelessness.20 About 70 percent of children and adolescents with dysthymic disorder eventually develop major depression.26 Diagnosis of minor depression requires t he presence of t wo out of t he nine sy mptoms for major depression (Table 3), one being depressed mood or decreased interest, and a t ime course similar to t hat of major depression. If present bet ween t he episodes of major depression, minor depression can be a risk factor for relapse.20 At y pical depression is characterized by hy persomnia, increased appet ite wit h carbohydrate craving, weight gain, interpersonal reject ion sensit ivit y, feeling of heaviness in t he arms and legs, and react ivit y of mood.20 It is relat ively common in children and adolescents.27 Presence of de presse d mood, i nc rease d slee p, decreased appet ite, a nd social isolat ion bet ween Oc tober a nd Februa r y of t wo consecut ive yea rs suggest s seasonal affec t ive disorder. Alt houg h less common, bipolar disorder is an important different ial diagnosis. In 40 percent of children and adolescents wit h bipolar disorder, t he illness begins wit h a major depressive episode.2 Risk factors for bipolar disorder are acute and early onset of depression, presence of psychot ic sy mptoms (e.g., hallucinat ions), significant psychomotor slowing, TABLE 2 family histor y of bipolar disorder, any mood Key Clinical Decision Points for Depressive Disorders disorder in t hree consecut ive generat ions of fa mily members, a nd a nt idepressa ntQuestion Action induced mania.28 Physicians should maintain a hig her level of sur veillance in pat ients Is th is depre ssi on c au s ed by a Ru l e out other c au s e s of depre ssive at greater risk of bipolar disorder. genera l med i c a l c ond i t i on , a mood d is orders. In severe major depression wit h psychosis, med i c at i on , or both? auditor y hallucinat ions (of ten crit icizing t he Is th is depre ssi on re l ated to drug Determ i ne whether s e c ondary to or or a l c oho l abu s e? c omp li c ated by sub s tan c e abu s e . pat ient) rat her t han delusions (as occur in Is th is depressi on re lated to a Consi der a d i agno sis of ad j u s tment adults) are present. This age-related varirea c t i on to a s tress fu l li fe event? d is order. abilit y in psychot ic sy mptoms may be a Is th is a c hron i c , m il d depre ssi on? Consi der dys thym i c d is order. result of differences in cognit ive maturaIs th is another type of depre ssive Consi der m i nor depre ssi on , b i po l ar t ion. Treat ment of major depressive disorder d is order? depre ssi on , depre ssi on c au s ed wit h psychosis requires t he combi nat ion by s ea s ona l affe c t ive d is order, or of an ant idepressant and an ant ipsychot ic atyp i c a l depre ssi on . medicat ion.29 Pat ients wit h t his disorder are Is th is ma j or depre ssi on? A pp ly DSM- I V cri teri a (s ee Tab l e 3) . at a greater risk of suicide and of ten require A ss e ss for s everi ty and p syc hot i c feature s. inpat ient psychiat ric admission.
Is there a c oexis t i ng menta l ill ne ss? Dys thym i c d is order, anxi ety d is orders, attent i on-def i c i t / hypera c t ivi ty d is order, oppo si t i ona l def i ant d is order, and sub s tan c e us e d is order are c ommon c omorb i d i t i e s. P erform su i c i de ris k a ss e ss ment .

Is th is a dangerou s depre ssi on?

DSM-IV = D i agnost i c and Stat ist i c a l Manua l of Menta l D isorders, 4th ed.

Suicide Risk Assessment During the first visit, physicians should assess the suicide risk of patients with depression and decide on the most appropriate treatment venue. Depressive disorders are the most common diagnoses present in all suicides. Twenty percent of teenagers
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TABLE 3

Criteria for Major Depressive Episode in Adults, Children, and Adolescents

The ri ght s ho l der d i d not grant the A meri c an A c ademy of F am ily P hysi c i an s the ri ght to sub li c ens e th is materi a l to a th ird party. F or the m issi ng i tem , s ee the ori g i na l pri nt versi on of th is pub li c at i on .

Adapted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. rev. Washington, D.C.: American Psychiatric Association, 2000:356, with additional information from references 21 through 24.

seriously contemplate suicide,30 and 8 percent attempt it.31 In 2001, there were 1,833 suicides in children and adolescents 10 to 18 years of age; and in 2000, suicide was the third leading cause of death among those 10 to 19 years of age.31 Su icidal commu n icat ion i n a ny for m must be 76 American Family Physician

taken seriously. Documentat ion of suicide risk should i nclude hig h-risk a nd protec t ive fac tors for suicide (Table 4).1,30-36 Pat ients wit h mult iple hig h-risk factors should be referred to a child and adolescent psychiat rist. However, pat ients wit h low-risk and protect ive factors (e.g., a close, warm, support ive family; religious beliefs
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TABLE 4

Childhood Depression

Risk Factors and Protective Factors for Suicide in Children and Adolescents
High-risk factors Biodemographics Age: l ate teens through early 20 s32 ; 20 perc ent of teenagers c ontemp l ate su i c i de , 30 and 8 perc ent attempt i t . 31 Sex: i deat i on and attempt s more c ommon i n fema l e s 32 ; c omp l eted su i c i de s f ive t i me s more c ommon i n ma l e s. 32 Ethn i c i ty: teenage su i c i de s are more c ommon i n wh i te s and H is pan i c s than i n b l a c k s ; rate s are h i ghe s t i n Nat ive A meri c an teens and l owe s t i n A si an teen s and tho s e from the P a c i f i c isl and s. History Ma j or depre ssi on: i n crea s e s the ris k of su i c i de 12-fo l d for both s exe s,1 e s pe c i a lly i f hope l e ss ne ss is a symptom Sub s tan c e abu s e: i n crea s e s the ris k of su i c i de1 about t wofo l d Condu c t d is order: li nked to one th ird of su i c i de s i n ado l e s c ent boys1 and i n crea s e s overa ll risk t wofo l d1 Current s tre ss ors or l o ss e s (e . g ., troub l e i n s c hoo l or w i th the l aw , l o ss of romant i c re l at i ons h i p , unwanted pregnan c y, i ntens e hum ili at i on) 33 P hysi c a l or s exua l abu s e 32 M i n i ma l c ommun i c at i on w i th parent s 34 Protective or low-risk factors

Bl a c k fema l e c h il d

No c urrent depre ssi on No c urrent a l c oho l or sub s tan c e abu s e Good prob l em-s o lvi ng and c op i ng s k ills No c urrent s tre ss ors or l o ss e s No h is tory of physi c a l or s exua l abu s e C l o s e support ive fam ily re l at i onsh i p s and good c ommun i c at i ons w i th parent s Ava il ab ili ty of parenta l support and c l o s e supervisi on duri ng s tre ss fu l li fe event Strong re li g i ou s be li ef or fa i th P o si t ive , hopefu l out l ook about future w i th s pe c i f i c po si t ive and c on crete p l an s and goa ls A b ili ty to art i c u l ate rea s on s to live A mb iva l en c e about su i c i de No a c t ive su i c i da l thought s or i ntent; no nonverba l su i c i da l behavi ors No h is tory of su i c i de attempt No fam ily h is tory of su i c i de No a cc e ss to f irearm s or toxi c sub s tan c e s

History of suicidal behavior Su i c i da l thought s w i th p l an: s pe c i f i c p l an s for su i c i de and the means to c arry i t out , i n c l ud i ng nonverba l su i c i da l behavi ors (e . g ., g ivi ng away va l ued po ss e ssi ons or c o ll e c t i ons) Previ ou s su i c i de attempt: one of the s tronge s t pred i c tors of c omp l eted su i c i de1 F am ily h is tory of su i c i de and depre ssi on 35 , 36 Ava il ab ili ty of f irearm s or toxi c sub s tan c e s Contagion effect M ed i a c overage of su i c i de: i m i tat i on p l ays a part i n su i c i da l behavi or, often fo ll ow i ng i nten s e med i a c overage of a c e l ebri ty su i c i de or a s tri ng of su i c i de s i n s c hoo l . 32
Information from references 1 and 30 through 36.

No extensive med i a c overage of su i c i de

against suicide; a posit ive f uture out look) are less likely to harm t hemselves32 and may be t reated as outpat ients. Parents or guardians should be asked to remove firearms and toxic substances, including nonprescript ion medicat ions, f rom t he pat ients environment and to provide appropriate super vision, especially during crises in t he child s life. They should be made aware of t he suicide risk t hat exists during t he early phases of ant idepressant t reat ment and t he need for addit ional super vision. Treatment Treatment options depend on the clinical situation and include cognitive behavior therapy alone or with antiJanuary 1, 2007

depressants. The risk/benefit ratio of antidepressant use should be considered. Physicians choosing to prescribe antidepressants must obtain fully informed consent and closely monitor clinical progress, behavioral activation (e.g., impulsivity, daring, silliness, agitation), and suicidality, especially in the initial stages of treatment.29 Followup should take place each week during the first month and every other week during the second month; subsequent frequency of follow-up visits should be determined by the clinical care needs of the patient. The choice of an antidepressant also may be guided by patient or family history of antidepressant response; side-effect profile; and drugdrug, drug-disease, and drug-food interactions.
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COGNITIVE BEHAVIOR THERAPY AND COUNSELING

Cognitive behavior therapy is effective for mild to moderate childhood depression.18,37-39 It entails reality-based challenges to pervasive, automatic, negative, distorted thoughts, with the goal of helping Children taking antideprespatients steer out sants should be monitored of a negative view closely for suicidality. of themselves, the past, and the future. Interpersonal psychotherapy is directed at resolving grief, coming to terms with interpersonal role transitions or role disputes, and correcting interpersonal skill deficits.18 Office-based counseling may involve: (1) educat ing pat ient s about healt hy copi ng skills, problem solving, conflict resolut ion, social and assert iveness skills, and relaxat ion techniques; (2) educat ing parents about realist ic, age-appropriate ex pec tat ions a nd nonjudgmental, noncrit ical patterns of communicat ion ; and (3) support ing healt hy behaviors, healt hy psychological defenses, and healt hy relat ionships.
ANTIDEPRESSANTS

The effectiveness and safety of various medications for depression in children and adolescents have been systematically studied and reviewed.18,37-51 Tricyclic antidepressants are ineffective in children and have limited effectiveness in adolescents, with safety concerns in both groups.18,40,41 There also is limited evidence for the effectiveness of selective serotonin reuptake inhibitors (SSRIs). In a systematic review of published and unpublished trials of SSRIs, published reports suggested favorable risk/benefit profiles for some SSRIs, but the addition of unpublished data shifted the risk/benefit ratio toward unfavorable, with the exception of fluoxetine (Prozac).42 In children and adolescents, there is limited or no evidence evaluating the use of lithium, monoamine oxidase inhibitors, St. Johns wort, and venlafaxine (Effexor).18 Most trials assessing t he use of SSR Is in children and adolescents are of short duration, have small numbers of participants, and are industr y-sponsored, t hus limiting t heir abilit y to detect or report major adverse events. Furt hermore, t here are high placebo response rates and met hodologic flaws in studies supporting SSR I use.43,52 For example, alt hough one study indicated t hat fluoxetine plus cognitive behavior t herapy was t he best choice, t he success of fluoxetine was found only in t he unblinded arms of t he study: t he blinded arms showed no better response t han wit h placebo.39 Finally, most studies are underpowered to address t he outcome of suicide. Concerns about t he effec t iveness, adverse effec t s 78 American Family Physician

(Table 5),18 and safet y of ant idepressant use have led to important reg ulator y changes in several count ries. Of part icular concern is t he associat ion of t he drugs wit h increased suicidal behavior.53 For example, t he U.S. Food and Drug Administ rat ion (FDA) counsels against using paroxet ine (Paxil) in children and adolescents because of effect iveness and safet y concerns.54 The Committee on Safet y of Medicines in t he United Kingdom analyzed SSR Is and considers t he risk / benefit rat io to be favorable on ly for fluoxet ine.44 Addit ionally, fluoxet ine is t he on ly SSR I approved by t he FDA for t he t reat ment of depression in children eig ht to 17 years of age. Fluoxet ine t herefore may be considered for t he t reat ment of moderate to severe depression in children. However, current evidence is inadequate to determine whet her safet y and effect iveness concerns represent a class effect or individual drug propert ies; t hus, all ant idepressants have a black box warning for increased risk of suicidal t houg hts and behavior in children and adolescents being t reated for depression.55 Before init iat ing an ant idepressant, physicians should ensure t hat a safet y plan is in place. This includes an agreement wit h t he pat ient and t he family t hat t he pat ient will be kept safe and will contact a responsible adult if suicidal urges are too st rong, and assurance of t he availabilit y of t he t reat ing physician or proxy 24 hours a day to manage emergencies.
DURATION AND MAINTENANCE OF TREATMENT

Evidence suggests that early intervention for depression in children can improve long-term outcomes.56 Duration of treatment depends on the number of previous episodes of depression. A minimum of six months of
TABLE 5

Common Adverse Effects of SSRIs

With SSRI use A kath isi a or motor re s t l e ss ne ss D i zz i ne ss Drow si ne ss Gas tro i nte s t i na l symptoms Heada c he Treatment-emergent ag i tat i on or ho s t ili ty Tremor With decrease or discontinuation of SSRI D i zz i ne ss Drow si ne ss F at i gue Heada c he I mpa ired c on c entrat i on L i ghtheadedne ss Nau s ea

SSRI = selective serotonin reuptake inhibitor. Information from reference 18.

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treatment is recommended in first episodes, with the drug tapered slowly over six to eight weeks to minimize the risk of withdrawal syndrome. For second episodes of depression, at least one year of treatment should be given. Patients with two or three previous episodes should be treated for at least one to three years, and patients with more than three previous episodes of depression should be treated indefinitely, especially if the episodes are severe or have psychotic features or suicidality.29 The dosage at which symptom relief is achieved often is the dosage for maintenance. Adjunctive psychotherapy and family therapy can help consolidate the gains.29 No optimal treatment duration for therapy has been determined. A child psychiat ric consultat ion is helpf ul for children wit h severe recurrent depression or t reat mentresistant depression. A diagnosis of t reat ment-resistant depression requires failure of t reat ment wit h t wo ant idepressants administered in adequate dosage for an adequate durat ion (at least six weeks). Pat ients wit h t reat ment-resistant depression may require addit ional medicat ion augmentat ion (e.g., lit hium). Adjunct ive cognit ive behavior t herapy also improves outcomes. Physicia ns uncomfor t able wit h prescribi ng complex t herapies should consider referral to a child psychiat rist, especially for pat ients wit h mult iple comorbidit ies.
The authors thank Christopher Kratochvil, M.D., Daniel R. Wilson, M.D., Ph.D., and Frederick Petty, M.D., Ph.D., for their review of and suggestions for the manuscript.

REFERENCES
1. Shaffer D, G ou l d MS , F is her P, Trautman P, M oreau D, K l e i nman M , et a l . P syc h i atri c d i agno sis i n c h il d and ado l e s c ent s u i c i de . Arc h Gen P syc h i atry 1996;53:339-48 . 2 . Birmaher B, Ryan ND, W illi am s on DE , Brent DA , Kaufman J , Dah l RE , et a l . Ch il dhood and ado l e s c ent depre ssi on: a rev i ew of the pa s t 10 years. P art I . J A m A c ad Ch il d Ado l e s c P syc h i atry 1996;35:1427-39 . 3 . Garris on CZ , Wa ll er JL , Cuffe SP, M c Keow n RE , Addy CL , J a c k s on KL . I n c i den c e of ma j or depre ssi ve d is order and dys thym i a i n young ado l e sc ent s. J A m A c ad Ch il d Ado l e s c P syc h i atry 1997;36:458-65 . 4 . A ngo l d A , Co s te ll o E J, Erkan li A , Worthman CM . P uberta l c hange s i n hormone l eve ls and depre ssi on i n g irls. Psyc ho l M ed 1999;29:1043-53 . 5 . P i ne DS , Cohen E , Cohen P, Brook J . Ado l e s c ent depre ssi ve symptom s a s pred i c tors of adu l t depre ssi on: mood i ne ss or mood d is order? A m J P syc h i atry 1999;156:133-5 . 6 . P i ne DS , Cohen P, Gurl ey D, Brook J , Ma Y. The ris k for earl y-adu l thood anx i ety and depre ssi ve d is orders i n ado l e s c ent s w i th anx i ety and depre ssi ve d is orders. Arc h G en P syc h i atry 1998;55:56-64 . 7. Kann L , K i n c hen SA , W illi am s BI , Ro ss J G , Lowry R , Grunbaum J A , et a l . Youth R is k Behav i or Surve ill an c e Un i ted State s, 1999 . State and l o c a l YRBSS Coord i nators. J S c h Hea l th 2000;70:271-85 . 8 . Brent DA . A ss e ss ment and treatment of the youthfu l s u i c i da l pat i ent . A nn N Y A c ad S c i 2001;932:106-28 . 9 . Nat i ona l I n s t i tute of M enta l Hea l th . Bl uepri nt for c hange: re s earc h on c h il d and ado l e s c ent menta l hea l th . Bethe s da , M d . : Nat i ona l Adv is ory M enta l Hea l th Coun c il s Workgroup on Ch il d and Ado l e s c ent M enta l Hea l th I ntervent i on , Prevent i on , and Dep l oyment , 2001. A cc e ss ed September 21, 2006 , at: http: // w w w . n i mh . n i h . gov / pub li c at / n i mhb l ue pri nt . pdf. 10 . Nat i ona l I n s t i tute of M enta l Hea l th . Depre ssi on i n c h il dren and ado l e sc ent s : a fa c t s heet for physi c i an s. Bethe s da , M d . : Nat i ona l I n s t i tute of M enta l Hea l th . A cc e ss ed September 21, 2006 , at: http: // w w w . menta l hea l th-matters. c om / art i c l e s / art i c l e . php?art I D = 320 . 11. Hariri AR , Mattay VS , Te ssi tore A , Ko l a c hana B, F era F, G o l dman D, et a l . Seroton i n tran s porter genet i c vari at i on and the re s pon s e of the human amygda l a . S c i en c e 2002;297:400-3 . 12 . Warner V, We iss man M M , Muf s on L , W i c kramaratne PJ . Grandparent s, parent s, and grand c h il dren at h i gh ris k for depre ssi on: a three-generat i on s tudy. J A m A c ad Ch il d Ado l e s c P syc h i atry 1999;38:289-96 . 13 . Wys ow s k i DK , P i tt s M , Be i tz J . A n ana l ysis of report s of depre ssi on and s u i c i de i n pat i ent s treated w i th is otret i no i n . J A m A c ad Dermato l 2001;45:515-9 . 14 . P i ne DS , Cohen P, Brook J . Ado l e s c ent fears a s pred i c tors of depre ssi on . Bi o l P syc h i atry 2001;50;721-4 . 15 . A ngo l d A , Co s te ll o E J , Erkan li A . Comorb i d i ty. J Ch il d P syc ho l P syc h i atry 1999;40:57-87. 16 . U . S . Prevent i ve Serv i c e s Ta s k F orc e . S c reen i ng for depre ssi on: re c ommendat i on s and rat i ona l e . A nn I ntern M ed 2002;136:760-4 . 17. Kova c s M . The Ch il drens Depre ssi on I nventory. North Tonawanda , N .Y. : Mu l t i -Hea l th Sys tem s, 1992 . 18 . Haze ll P. Depre ssi on i n c h il dren and ado l e s c ent s. C li n Ev i d 2004;12: 427-42 . 19 . T i mbremont B, Braet C , Dree ss en L . A ss e ssi ng depre ssi on i n youth: re l at i on bet ween the Ch il drens Depre ssi on I nventory and a s tru c tured i nterv i ew . J C li n Ch il d Ado l e s c P syc ho l 2004;33:149-57. 20 . A meri c an P syc h i atri c A ss o c i at i on . D i agno s t i c and Stat is t i c a l Manua l of M enta l D is orders : DSM- I V-TR . 4th ed . rev. Wa s h i ngton , D . C . : A meri c an P syc h i atri c A ss o c i at i on , 2000 . 21. Birmaher B, W illi am s on DE , Dah l RE , A xe ls on DA , Kaufman J , Dorn LD, et a l . C li n i c a l pre s entat i on and c ours e of depre ssi on i n youth: doe s on s et i n c h il dhood d i ffer from on s et i n ado l e s c en c e? J A m A c ad Ch il d Ado l e s c P syc h i atry 2004;43:63-70 .

The Authors
SHASHI K. BHATIA, M.D., is a professor of psychiatry, child and adolescent psychiatry, and pediatrics, and director of the Division of Child and Adolescent Psychiatry at Creighton University School of Medicine, Omaha, Neb. She also is medical director of the Child and Adolescent Residential Treatment Center at Alegent Health Midlands Hospital, Papillon, Neb. Dr. Bhatia received her medical degree from Panjab University, Chandigarh, India. She completed a residency in obstetrics and gynecology at the Postgraduate Institute of Medical Education and Research, Chandigarh, and a residency in psychiatry and a fellowship in child and adolescent psychiatry at Creighton University. SUBHASH C. BHATIA, M.D., is professor and vice chair of the Department of Psychiatry, Creighton University, and associate professor at the University of Nebraska College of Medicine, Omaha. He also is chief of the Mental Health and Behavioral Sciences Department at the Department of Veterans Affairs, NebraskaWestern Iowa Health Care System, Omaha. Dr. Bhatia received his medical degree from Panjab University and a graduate degree from the Postgraduate Institute of Medical Education and Research, Chandigarh. He completed a residency in psychiatry at Creighton University.

A ddre ss c orre s ponden c e to S ubha s h C . Bhatia , M . D ., Chief , M ental Health and Behavioral Scien c e s Dept ., VA Nebra s ka We s tern I o w a Health Care Sy s tem , 4101 Woolw orth Ave ., O maha , NE 68105 (e-mail: s ubha s h . bhatia @ med .va . gov) . Reprint s are not available from the author s .
Author disclosure: Nothing to disclose.

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