Children and adolescents hospitalized for the treatment of physical illness often have feelings of sadness, frustration, or irritability that represent a normal response to their experience. Common factors impacting a child’s ability to cope include disruption of routine, separation from family and peers, uncertainty regarding diagnosis and prognosis, pain related to the illness or its treatment, and fear of the illness or its sequelae. When the sadness becomes pervasive and is associated with cognitive or physiologic symptoms, however, a depressive disorder must be considered. It is incumbent on the hospitalist to distinguish normal feelings of sadness from a depressive disorder and to implement treatment when necessary.

Chronically ill children are at increased risk for developing depressive, anxiety, and eating disorders.^1-5 Clinical depression has been reported to increase the risk of poor physical health in the future⁶ and has been associated with poor adherence to treatment regimens,⁷ reduced immune function,⁸ increased disease severity, and death due to nonadherence.⁹ Emerging data suggest that depression in patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is associated with declining CD4 counts, accelerated disease progression, and increased mortality.¹⁰ In addition, suicidal ideation and suicide attempts are tragic consequences of depression that increases with the onset of puberty.¹¹ Depressive disorders cause significant suffering on the part of the child and family and are generally highly treatable once they are recognized. The purpose of this chapter is to provide the pediatric hospitalist with a framework for understanding the diagnosis and treatment of depressive disorders in children and adolescents with physical illness.

PATHOPHYSIOLOGY

While multiple theories exist regarding the pathophysiology of depression (Table 135-1), conclusive evidence of its etiology is still uncertain. The Diagnostic and Statistical Manual (DSM) bases the diagnosis of depression on a cluster of symptoms. As the DSM is atheoretical by design, it is important to note that patients who may look similar phenotypically for depression may indeed have different etiological mechanisms for their depression. As such, simply making a diagnosis of depression does not indicate the pathophysiological mechanism or the optimal treatment regimen.

Additional factors further complicate the diagnosis of depression. First, the term depression is ambiguous and has many connotations. It may be used to describe a transient mood state or one of several clinical syndromes of varying severity. Second, because symptoms of depressive disorders are subject to developmental variation, they may present differently depending on the child’s stage of development.¹¹ Third, because medical and nursing staff often view depression as a normal and understandable response to a chronic, terminal, or disfiguring illness, psychiatric evaluation and treatment may not be pursued.¹² Fourth, patients and families may be resistant to exploring the possibility of a depressive disorder because of the perceived stigma of a psychiatric diagnosis. Last, the diagnosis of depression is made on the basis of a constellation of psychological and somatic symptoms. As somatic symptoms are commonly seen in physical illness, it is often difficult to determine whether the symptoms are related to the physical illness or to a depressive disorder.

The symptoms of depressive disorders can be divided into two general realms: psychological and somatic. Psychological symptoms include dysphoric mood, anhedonia (loss of interest in usual, pleasurable activities), feelings of helplessness or hopelessness, feelings of guilt or worthlessness, loss of self-esteem, decreased ability to concentrate, and thoughts of suicide. Somatic symptoms of depression include fatigue, sleep disturbance (insomnia or hypersomnia), appetite changes (decrease or increase), and motor restlessness or retardation (see Chapter 137 for a discussion of somatic symptom and related disorders). The hospitalist should focus on the psychological symptoms because of the frequent overlap between somatic symptoms of depression and symptoms of the physical illness.

The presentation of depression depends on the child’s stage of development, and depression in children may manifest differently from depression in adolescents. Signs of depression in children (or in older children with developmental delay) may include feelings of sadness, a depressed appearance, somatic complaints (most commonly stomachaches and headaches), separation anxiety, low self-esteem, social withdrawal, academic decline, sleep or appetite disturbances, decreased concentration, and suicidal thoughts.¹¹

In adolescents, depression frequently presents with an irritable rather than a depressed mood. Additional symptoms commonly associated with depression in adolescents include behavioral disturbances, motor hyperactivity, feelings of being unloved, self-deprecation, tearfulness, hopelessness, low self-esteem, hypersomnia, lethargy, anhedonia, weight gain, decreased concentration, declining school performance, psychomotor retardation, feelings of being misunderstood, and suicidal ideation. Adolescents frequently do not recognize their symptoms as being part of a depressive disorder and may not report them unless specifically asked.¹¹

The hospitalist should consider the diagnosis of depression in patients who report feelings of sadness or who appear sad or withdrawn, in patients who exhibit oppositional behavior (e.g. refusal to participate in self-care or nonadherence to a treatment plan), or in patients with a history of other psychiatric disorders (e.g. anxiety, bipolar disorder, substance abuse). Studies have estimated that 40% to 70% of adolescents with depressive disorders also meet the criteria for at least one other psychiatric disorder.¹¹

The next step is to determine into which diagnostic category the patient’s symptoms best fit. Depressive symptoms in hospitalized children and adolescents typically fall into one of three categories, although overlap is common: adjustment disorder with depressed mood (situational depression), depressive disorder related to a general medical condition or substance, and primary psychiatric disorders, such as major depressive episode or dysthymia (persistent depressive disorder).

Adjustment disorder with depressed mood (situational depression) involves symptoms such as depressed mood, tearfulness, or feelings of hopelessness that arise in response to an identifiable stressor. Illness, hospitalization, and medical or surgical procedures are the stressors typically identified in hospitalized children. Patients frequently appear sad and tearful and may not be motivated to participate in their treatment regimens. They may describe feeling overwhelmed by their illness or its treatments and may report feeling hopelessness or fear that they will never leave the hospital. Depressive symptoms typically resolve when the stressor is removed and the patient is able to resume his or her usual routine following discharge from the hospital.

Certain medical conditions, medications, and drugs of abuse may be associated with depressive symptoms and should be considered in the differential diagnosis of depression (Table 135-2).

A mood disorder due to a general medical condition refers to a significant and persistent disturbance in mood that is the direct physiologic effect of a medical condition. A substance-induced mood disorder is the direct effect of a medication or drug of abuse. In both disorders, symptoms may range from depressed mood or anhedonia to multiple psychological and somatic symptoms of depression. A clue to the diagnosis is a temporal relationship between the onset, exacerbation, or remission of the mood disturbance and the medical disorder, medication, or drug of abuse.^13,14

Primary psychiatric disorders such as major depressive episode and dysthymic disorder (persistent depressive disorder) should also be considered in the differential diagnosis of depressive symptoms. A major depressive episode is an acute episode (at least 2 weeks) of pervasive sadness or anhedonia in conjunction with four or more other symptoms of depression such as poor appetite, weight loss, poor sleep, poor concentration, loss of energy or recurrent thoughts of death. The patient must experience significant distress or functional impairment (e.g. decline in social or academic performance), and the symptoms cannot be the direct physiologic effects of a medical condition or substance (e.g. medication, drug of abuse).¹⁵ Dysthymic disorder (persistent depressive disorder) refers to a chronically depressed or irritable mood most of the time for at least 1 year (2 years in adults), with any remission in symptoms lasting less than 2 months, in conjunction with two or more of the following symptoms: insomnia or hypersomnia, poor or excessive appetite, decreased energy, poor concentration, low self-esteem, and feelings of helplessness. The symptoms must cause significant distress or functional impairment and cannot be the direct physiologic effects of a medical condition or substance.¹⁵ Primary psychiatric disorders are more common in patients with a history of previous depressive episodes or a family history of depression.

When the hospitalist suspects depression, psychiatric consultation should be obtained if available. If unavailable, the hospitalist should complete the assessment as follows. The first step is to meet with the patient and his or her parents or guardians to obtain the following information: past individual and family psychiatric histories, description of academic performance and peer relations, and drug or alcohol use. In addition, the hospitalist should inquire about current and past psychosocial stressors, perform a mental status examination, and screen for the psychological and somatic symptoms of depression. These symptoms can be remembered using the mnemonic SIGECAPS, which refers to a prescription one might write for a depressed person (sig.: energy capsules). Each letter refers to one of the diagnostic criteria for a major or clinical depressive episode (Table 135-3).^15,16