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Primary care nurse
practitioners are among the first to see symptoms suggestive of depression
in children and teens. They should be able to screen high-risk patients.
Young children may present for somatic complaints, but also show little
interest in play, aggression, and/or declining school performance. Adolescents
may also display rebellious and risky behaviors. The diagnosis of depression
should be considered if signs persist daily beyond three weeks. Primary
assessment includes family, developmental and medical history.
Initial diagnosis should be conducted in a mental health setting using
multiple sources of information. Differential diagnosis includes anxiety,
attention deficit, and bipolar disorders. Depression rating scales include
the Children's Depression Inventory and Reynolds Child Depression scale/
Adolescent Depression scale. Accurate diagnosis is important to select
appropriate drug and psychotherapeutic interventions.
Medication decisions consider target symptoms and side effects. Most pediatric
prescriptions for depression are off-label. The Food and Drug Administration
(FDA) approved only fluoxetine for depression in children ages 8 years
and older; fluoxetine and sertraline are approved for obsessive compulsive
disorder in children as young as 7 or 6 respectively. The prescribing
clinician should keep documented parental informed consent for use of
any psychotropic drug (approved or off-label) and assure that parents
receive a drug information sheet which includes symptoms that need immediate
attention.
Select serotonin reuptake inhibitors (SSRIs) are a well known group, but
each formulation affects specific serotonin receptor sites. This explains
some variability in efficacy with targeted symptoms and side effects,
e.g., nausea, restlessness or sedation. For example, fluoxetine stimulates
the 5HT2 receptor so it is not the first choice for children with co-morbid
anxiety. Medication changes require tapering to avoid discontinuation
syndrome. The order for SSRIs or other anti-depressants should consider
the family's culture and any dietary or herbal products that may affect
drug metabolism.
Psychotherapy with play therapy, family counseling and cognitive behavioral
therapy are useful. Ideally, primary care and mental health practitioners
collaborate to coordinate appropriate interventions and medications. Family
therapy is often crucial to successful outcomes, but parents may discontinue
counseling and only want the medication for their child. The nurse practitioner
can emphasize the importance of continuing therapy to improve communication
patterns and roles within the entire family.
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