Pediatric Major Depressive Disorder: Questions to Consider

What are the options for treating major depressive disorder in children and adolescents? This case offers readers a chance to give their feedback and to interact with the authors, who will present teaching points based on your comments.

Children and adolescents with depression often face problems in school and at home. They can be at increased risk for substance abuse, recurrent depression in adulthood, and even attempted or completed suicide. In addition to acute-phase treatments, it is becoming increasingly accepted that these patients need longer-term treatments (continuation and maintenance phase interventions).

Here the authors present a case that involves at least one diagnostic or therapeutic decision dilemma. We invite your comments below. The authors will review your responses and give their feedback in coming weeks.

Questions to consider when reading the case:

1. What treatment strategies would be useful for Travis in order to increase his academic performance?

2. If sleep difficulties persisted following sleep hygiene practices suggestions, what other treatment strategies would be helpful?

3. When would be the optimal time for Travis’ psychiatrist to taper off his medication?

4. How would treatment shift if Travis’ suicidality increased, which he attributed to family conflict and stress?

CASE VIGNETTE

Travis is a 10-year-old boy who presented with his first episode of major depressive disorder (MDD) to the outpatient psychiatry clinic. His symptoms at baseline included the following:

• depressed mood

• irritability

• anhedonia

• feelings of worthlessness

• negative self-image

• fatigue

• concentration difficulties

• sleep disturbance

• increased appetite

• suicidal ideation

In addition, he reported high levels of family stress and chaos and feeling “unimportant.” Although he had been a good student, his academic performance had declined. His baseline depression severity, as assessed by a clinician rating scale of depression, indicated severe depressed mood.

Treatment response was seen at 6 weeks of open treatment with fluoxetine, although he was not yet in remission. At that point, relapse-prevention CBT was initiated to address the remaining symptoms, which included mild depressed mood, irritability, sleep problems, and negative self-image.

Psychotherapy consisted of 12 sessions over 6 months. To address continued mood problems, behavioral coping strategies were developed collaboratively between Travis and his therapist. Sleep hygiene practices were introduced to improve sleep. In addition, the therapist introduced cognitive strategies to address Travis’s negative self-perception. Travis particularly identified with the concept of challenging negative thoughts and created his own phrase, “Drop the negative and catch the positive.”

Family sessions focused on helping the family understand risk factors for relapse, including negative emotion in the home. In addition, the therapist focused on increasing positive communication strategies. This included use of praise, contingency management, and focusing on the patient’s strengths. The therapist collaborated with Travis and his family to develop a wellness plan that included enjoyable family activities, such as volunteering at the local food bank and weekly family game nights.

After 6 months, Travis’s symptoms of depression were in remission and remained in remission at week 30.

For the discussion, please see "Continuation Treatment and Relapse Prevention in Pediatric Depression," from which this case is adapted.