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Depression in Children: Information for Primary Care

Summary: Children can become depressed just as adolescents and adults can. Look for red flags for childhood depression, and refer to mental health services and supports when depression is suspected. With children, interventions focus on optimizing the parent-child relationship, as well as supporting parents (whereas services for adolescents and adults often have more an individual focus).

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Note: If you are looking instead for information about depression in adolescents (aged 6-18), please see our module about Depression in Adolescents.

Case

You are seeing D., a 5-yo female brought by her mother for problems with depressed mood. Your assessment shows that indeed, she meets criteria for major depression. Mother has had longstanding struggles with depression as well, along with post-partum depression following D's birth. She loves her daughter, but life has not been easy for the mother.

Epidemiology of Childhood Depression

Prevalence

● 1% of preschoolers (age 3-5) (Luby, 2010)

● 2% children (i.e. under 12) (Birmaher, 2007)

● 4-8% adolescents (age 12-18) (Birmaher, 2007)

Risk factors include:

● Family history, particularly parents with depression

Prognosis

● Preschool depression has 50% persistence rate

● Mother with mental health issues is a negative prognostic factor

All the above highlight the importance of the importance of early screening for early childhood depression, and the importance of ensuring mental health care for parents.

Normal Development

Infants, children and youth require various things for well being:

Physical well being, which includes proper nutrition, opportunities to move and be outside, along with shelter and access to medical care.
Emotional well being, which includes having healthy attachments with caregivers (so that they can feel a sense of belonging), with a sense of
Belonging (includes attachment),
Purpose (e.g. work, school, or the other things we do in life that keep us busy)
Meaning (i.e. knowing that our life has meaning)
Hope (e.g. knowing that will continue to go well, or will get better in the future)

When our needs are unmet, we may struggle with mental wellness (and thus depression) …

Primary care providers are uniquely poised to identify and provide early intervention at early stages…

Clinical Presentation

Depression in infants, toddlers and children presents somewhat differently compared to adults.

Depression in Infants / Toddlers

When “depressed”, infants and toddlers may present with ‘depressive equivalents’, such as

Failure to thrive
Problems with attachment, i.e. insecure attachment, which is a When faced with parental separation, the infant/toddler that is
Avoidant: Doesn’t seem to react when caregivers leave ; Doesn’t cry, nor turn to parents for his/her needs
Anxious : Overly anxious with parental separation, “clings on” to parents
Disorganized: Odd or ambivalent behavior with separation or reunion, e.g. When parent returns, may initially seek out parent but then run away, curl up in a ball, hit the parent (i.e. fight/flight/freeze)

Clinical Presentation of Depression in Preschoolers (age 3-5)

Depressed preschoolers may appear (Luby, 2000)

Less joyful;
More prone to guilt;
Fail to enjoy activities and play;
Changes in sleep, appetite, and activity as compared to healthy peers.

Often undetected by parents/caregivers, as symptoms less disruptive (than in older children).

Clinical Presentation of Depression in Children (age 6-12)

Children may have

Mood lability,
Irritability,
Low frustration tolerance,
Temper tantrums,
Somatic complaints,
Social withdrawal
They may be able to say they are sad or depressed.

Screening / Identification

Consider using screening questions based on the PHQ-4 (Centre of Effective Practice, 2017). Although recommended for patients aged 12 and above, the questions may be modified for use with children.

Consider asking the parent:

Anxiety screening
Clinician (to parent):	Over the past 2-weeks, how often has your child been bothered by feeling nervous, or on edge? Or not being able to stop or control worrying?
Depression screening
Clinician (to parent):	Over the past 2-weeks, how often has your child had little interest or pleasure in doing things? Feeling down, depressed or hopeless?

For older children, consider asking the questions to the child directly as well, for example:

Anxiety screening
Clinician (to parent):	Over the past 2-weeks, have you been bothered by feeling nervous, or on edge? Or not being able to stop or control worrying?
Depression screening
Clinician (to parent):	Over the past 2-weeks, have you felt that things aren’t any fun, or boring? have you felt sad, down or depressed?

If these screening questions are positive, consider exploring more in-depth for mood and/or anxiety disorders.

Screening Tools

In order to efficiently gather more information about possible depression, you might consider using the following screening tools:

Preschool Feelings Checklist (for depression)	Created for primary care to screen for depression 20-items Ages 3-5 yo Free http://www2.tulane.edu/som/tecc/upload/Preschool-feelings-checklist.pdf
Center for Epidemiological Studies Depression Scale for Children (CES-DC)	Ages 8-17 Free https://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf
Pediatric Symptom Checklist-17 (PSC-17)	Can help primary care providers assess the likelihood of finding any mental health disorder in their patient Ages 4-16 Free https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
Depression Self-Rating Scale for Children	18-item self-rating scale Ages 8-14 Scoring Children who scored 15 and over on the DSRS were significantly more likely to have a depressive diagnosis (Major Depression or Dysthymia) Free http://www.scalesandmeasures.net/files/files/Birleson%20Self-Rating%20Scale%20for%20Child%20Depressive%20Disorder.pdf

History

Key questions include:

When did the depression start?
Safety assessment
- Any thoughts that life isn’t worth living?
- Any thoughts about ending your life?
Symptoms of depression
- Problems with mood
- Problems with sleep, appetite, energy, concentration
Psychiatric review of symptoms to rule out other conditions such as
- Anxiety
- Psychosis
- Substance Use
- Substance use
Any use of alcohol? Recreational drugs?
- Although alcohol / substance use is uncommon in aged 6-12, there are nonetheless certain populations that are higher at risk where it makes more sense to ask (e.g. children/youth that suffer from poverty, indigenous children, and those with parents with substance use.)
Any particular stressors?
- Home?
- School? Such as teacher, peers, academics?
- Any abuse or trauma?
Interpersonal inventory
- Who are the key people in the child’s life?

Diagnoses

Diagnostic Criteria for Preschool Major Depressive Disorder (Age 3-5)

The problem with using standard DSM-IV criteria for depression in preschoolers (aged 3-5), is they miss 76% of preschoolers that were felt to be depressed (Luby, 2002). Thus, the following modified criteria have been developed and validated for preschoolers (Luby, 2002):

Five (or more) of the following symptoms have been present but not necessarily persistently over a 2-week period and represent a change from previous functioning: at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure in activities or play. If both (1) and (2) are present, a total of only four symptoms are needed.

Depressed mood for a portion of the day for several days, as observed (or reported) in behaviour. Note: May be irritable mood.
Markedly diminished interest or pleasure in all, or almost all, activities or play for a portion of the day for several days (as indicated by either subjective account or observations made by others).
Significant weight loss when not dieting, or weight gain or decrease or increase in appetite nearly every day.
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) that may be evident in play themes.
Diminished ability to think or concentrate or indecisiveness, for several days (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without specific plan, or a suicide attempt or a specific plan for committing suicide. Suicidal or self-destructive themes are persistently evident in play only.

DSM-5 Depression in Child/Adolescents

These criteria are provided here for reference, though note that they may be more accurate for adolescents than children (Luby, 2002).

5 or more symptoms present during a 2 week period which includes:

Depressed or irritable, cranky mood (outside being frustrated) or
Loss of interest or pleasure

Plus any three of the following:

Significant weight loss or decrease in appetite (more than 5 percent of body weight in a month or failure to meet expected weight gains.)
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or lack of energy
Feelings of worthlessness or guilt
Decreased concentration or indecisiveness
Recurrent thoughts of death or suicide

DSM-5 Childhood Persistent Depressive Disorder (formerly known as dysthymia, dysthymic disorder)

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others.

In children and adolescents, mood can be irritable and duration must be at least 1 year (vs. 2-years for adult dysthymia)

B. Presence, while depressed, of two (or more) of the following:

Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feeling of hopelessness

During the 2 year period (1 year for children of adolescents) of the disturbance, the individual has never been without symptoms in Criteria A and B for more than 2 months at a time. Criteria for a major depressive disorder may be continuously present for 2 years.

Differential Diagnoses

Many conditions can lead or contribute to mood problems including but not limited to:

Psychiatric diagnoses

Normal Mood	It is normal for children to have periods of low moods. “Normal” low moods are transient, and not associated with significant problems with function nor physical symptoms.
Adjustment Disorder with Depressed mood	Difficulties adjusting to a stressful situation, that have led to depressed mood, but without neurovegetative symptoms sufficient to meet for major depressive disorder
Dysthymic Disorder	Problems with mood that have persisted more than 1-year (in children/youth)
Anxiety	Any problems with feeling excessively anxious? Shyness?
Attention deficit hyperactivity disorder (ADHD)	Any problems paying attention? Problems with hyperactivity? Impulsivity?
Learning disability	Learning disability, e.g. the child who struggles in school due to learning issues, which thus lead to frustration and mood problems
Disruptie mood dyregulation disorder (DMDD)	Any problems with excess anger or frustratoin? Temper tantrums? Rages?
Bipolar disorder	Episodic mood swings? Circadian rhythm disturbance? E.g. staying up all night despite high energy
Autism spectrum disorder (ASD)	Child disconnected and unable to relate to others
Sensory processing problems	Child with sensory overload

Medical Differential Diagnoses

Anemia	Any problems with low energy? Any risk factors such as vegetarianism?
Hypothyroidism	Thyroid problems (hypo and hyper),
CNS diseases	Brain tumors
Respiratory	Sleep apnea
Neoplastic	Any signs such as unexplained weight loss?
Infectious	Any signs of infection?

Physical Exam

There are no specific physical exam findings to major depressive disorder. Physical exam is important to rule out medical conditions that may mimic, or contribute to a mental health condition such as

Thyroid or endocrine problems
Infections such as meningitis, infectious mononucleosis
Neurologic conditions such as tumors
Tumors such as pancreatic cancer

Investigations

General screening tests based on clinical suspicion might include:

CBC with differential
Electrolytes, glucose, Ca
Renal function (e.g. BUN/Cr)
Thyroid screen, e.g. TSH
Urinalysis with drug screen
Liver enzymes
Iron screen, e.g. serum transferrin
B12 / folate

Additional specific investigations might be indicated depending on clinical suspicion such as:

HIV antibody screen
ESR
Mg for Mg deficiency
For Wilson’s disease: Serum copper and ceruloplasmin
For porphyria: 24-hr urine porphyrin levels
For heavy metal toxicity: Blood or urine levels for lead, mercury, or other suspected heavy metals
For autoimmune: Autoantibody screen and Igs
For infectious causes: Cultures for infectious agents
For alcohol use problems: Blood alcohol level; GGT; triglycerides
For phaeochromocytoma: Urine catecholamines

Management/Treatment: Primary Care Interventions

Education about depression

“Thank you for coming in today. I have bad news and good news… The bad news it appears your child has symptoms of depression. The good news is that there are many things we can do to support, and treat the depression."

Lifestyle strategies

Ensuring healthy sleep routines
Ensure proper nutrition
Ensure regular nature time: For proper eye health, a minimum of 10 hrs outdoors per week has been suggested. Note that some studies suggest that recommending nature time is even more important than recommending physical activity, because as long as kids get outside, they will be physically active.
Physical activity: Standard guidelines recommend at least 1-hr daily of physical activity for children.
Limits on screen time: No more than 1-2 hrs day of screen time for the average child (Canadian Paediatric Society Screen Guidelines). In children with emotional/behavioural issues however, circumstances might warrant less screentime.

Relationship and communication strategies

Teach parents how to listen and provide empathy, validation and acceptance of their child’s feelings. When a child is depressed, it indicates that the child has distressing feelings which they have been unable to regulate or manage. Thus, it is important that the child be able to 1) turn to parents with those feelings, and 2) parents be able to soothe and support the child with these feelings.
You might say the following to parents
- Your child needs your help in managing their difficult feelings, whether it is feeling sad, worried or upset.
- If your child is expressing difficult feelings, then
  - Listen without interrupting, and without jumping to giving advice or telling them what to do
  - Empathize and validate how your child feels, e.g. saying “It sounds like you are feeling sad. I can help you with your feelings. Let me give you a hug. Here’s a tissue paper… Its okay if you want to cry.
Family routines (e.g. family dinner, 1:1 time)
Ensure that the family has routines which allow family connection, e.g. family dinners and family activities
Ensure that the child has 1:1 time with a parent as well – it is during 1:1 time that the child will feel more comfortable in talking about topics such as their true feelings, stresses and other issues.

School Intervention.

If a child is having depression, most likely there is some impairment at school. Or school may be one of the contributing stresses that could be addressed
During an appointment, consider calling the school, and/or writing a school letter to let them know about the child’s needs for accommodations/modifications ]
Consider writing a sample letter to school in which you state the child’s needs, and recommend modifications/accommodations for the child’s needs. For children with depression, one particularly important intervention is ensuring that there are key school personnel that connect to the child regularly to see how the child is student and how they can support the student.
For a sample letter:
Visit “Depression in Children and Youth “ at http://primarycare.ementalhealth.ca/index.php?m=fpArticle&ID=18300
Click on “School/Workplace Letters”

Problem-Solving any particular Stressors

Identifying and solving specific problems or stresses is a strategy that can be done in primary care (GLAD-PC Guidelines, 2007)
The primary care provider works with the patient/parents to solve problems using the following seven steps

Step	What a clinician might say
1. Explore what possible stresses or problems the child/family is facing	Clinician: “Everyone has stresses. Typical stresses include home stresses, such as stresses with home routines, expectations, parents, siblings. Typical school stresses include teachers, schoolwork and classmates, including peer pressure and bullying.
2. Choose a specific problem or stress to address	Clinician: “What is a problem/stress that we should address?”
3. Set a realistic goal	Clinician: “What would you like to see different or better?” Examples include therapeutic strategies such as improving sleep, getting more activity; or dealing with stresses
4. Generate multiple possible solutions; start with the patient/family’s preferences first	Clinician: “Let’s see if we might come up with some possible solutions. First, let’s start off with your thoughts first.” After that, one might ask, “Would it be okay if I made some suggestions?”
5. Compare the different possible solutions, and pick one to try out.	Clinician: “Let’s review all the possible solutions to try. Which one would you like to try first?” If the solutions are complicated, consider writing out pros/cons for each.
6. Wrap up the session, and	Clinician: “Okay, so you’ll try out this solution and see how it goes. At our next visit, we’ll talk about how it goes.
At the next visit
1. Evaluate the strategy tried and see if it was helpful.	Clinician: “Let’s review how things went with ___. How did things go with ___?”
2. If helpful, great.	Clinician: “It sounds like the strategy worked. That’s wonderful!”
3. If not, then try a new strategy.	Clinician: “I’m sorry to hear things didn’t work out as well as hoped. Let’s talk more about that…”

Management/Treatment

First-line

Parent interventions: For depressed children (aged 0-12), start with parent interventions (as opposed to starting with child interventions such as individual therapy); Group and individual CBT with children (under aged 12) are less effective.

If available, Parent Child Interaction Therapy-Emotion Development (PCIT) is an evidence-based treatment for depression in age 3-7 yo. It consists of 18 sessions, in which parents receive coaching and guidance on how to support their child with negative emotions. Though it is not widely available, it supports the rationale for interventions to improve parent’s ability to meet the child’s needs.
Parent mental health services: Does the parent have unmet mental health needs? If the parent has ongoing mental health difficulties, then ensuring supports for the parent’s mental health may be particularly high yield as well

Second-line

If dysfunction despite non-medication strategies, might consider SSRIs.

Medications for Depression in Children/Youth

SSRIs	Start / Initial Target Dosage	Max Dosage
First Line SSRI
Fluoxetine (Prozac)	Child: Start 5 mg daily; initial target 5-10 mg daily Youth: Start 5-10 mg daily; initial target 10-60 mg daily	Child: Max 40 mg daily Youth: Max 80 mg daily
Second-line SSRI
Escitalopram (Cipralex or generic)	Child: Start 2.5 - 5 mg daily; initial target 5-10 mg daily Youth: Start 5 mg daily; initial target 5-10 mg daily;	Child: Max 10 mg daily Youth: Max 20 mg daily
Citalopram (Celexa or generic)	Child: Start 5 mg daily; initial target 5 mg daily Youth: Start 10 mg daily; initial target 10 mg daily	Child: Max 20 mg daily Youth: Max 40 mg daily
Sertraline (Zoloft or generic)	Child: Start 25 mg daily; initial target 50 mg daily Youth: Start 50 mg daily; initial target 100 mg daily	Child: Max 100 mg daily Youth: Max 200 mg daily
Others
Fluvoxamine (Luvox or generic)	Child: Start 25 mg daily; initial target 75 mg daily Youth: Start 25-50 mg daily; initial target 100-150 mg	Child: Max 150 mg daily Youth: Max 300 mg daily
Paroxetine (Paxil or generic)	Child: Start 5 mg daily; initial target 10 mg daily Youth: Start 10 mg daily; initial target 20 mg daily * Not usually used due to short half-life	Child: Max 30 mg daily Youth Max 60 mg daily

Case: 5-yo D., Part 2

You do the following:

Refer her parents to the local publicly funded children’s mental health agency that provides parents with a program in positive parenting (Triple P program). Mother learns new ways to meet her daughter’s needs, that she never experienced during her own upbringing. Dahlia’s mood improves, however she continues to have some symptoms of depression. As a result, she starts with an individual counselor, who learns more about her issues. The counselor also meets with parents and helps them understand Dahlia’s mental health needs and ways to support her.

Conflicts of Interest

Author: Michael Cheng, Project ECHO® Ontario CYMH

Relationships with commercial interests: Grant funding from the uOttawa Brain and Mind Research Institute for the eMentalHealth.ca/ PrimaryCare (for project personnel such as web development), of which one of the sources was Lundbeck/Otsuka, which markets Citalopram (Celexa).

Disclosure of commercial support: not applicable

Conflict of interest: none for this session

Mitigating potential biases: This module was created independently with no review from Lundbeck/Otsuka.

References

Child/Youth MH Tool, Centre of Effective Practice 2017.

Luby J: Preschool depression: Importance of Identification of Depression Early in Development, Curr Dir Psychol Sci. 2010 May 10; 19(2): 91-95.

Luby et al.: Preschool major depressive disorder: preliminary validation for developmentally modified DSM-IV criteria. J Am Acad Child Adolesc Psychiatry. 2002 Aug;41(8):928-37.

https://www.ncbi.nlm.nih.gov/pubmed/12162628

Birmaher et al.: Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders, J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46(11): 1503-1526.

Jensen P, Cheung A, Zuckerbrot R, Ghalib K, Levitt A: Guidelines for Adolescent Depression in Primary Care (GLAD-PC), 2010.

About this Document

Written by members of the eMentalHealth.ca Primary Care Team, which includes Drs. Mireille St-Jean (Family Physician, Ottawa Hospital) and Dr. Michael Cheng (Psychiatrist, Children’s Hospital of Eastern Ontario).

Special thanks to Dr. Kathi Pajer (Child Psychiatrist, Children’s Hospital of Eastern Ontario) for content expertise.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

Creative Commons License

You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/

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Depression in Children and Youth: Information for Parents and Caregivers

Date Posted: Feb 12, 2018
Date of Last Revision: May 16, 2020

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Depression

Parenting

Attachment Therapies

Table of Contents

Case

Epidemiology of Childhood Depression

Normal Development

Clinical Presentation

Depression in Infants / Toddlers

Clinical Presentation of Depression in Preschoolers (age 3-5)

Clinical Presentation of Depression in Children (age 6-12)

Screening / Identification

History

Diagnoses

DSM-5 Depression in Child/Adolescents

DSM-5 Childhood Persistent Depressive Disorder (formerly known as dysthymia, dysthymic disorder)

Differential Diagnoses

Physical Exam

Investigations

Management/Treatment: Primary Care Interventions

Management/Treatment

Medications for Depression in Children/Youth

Case: 5-yo D., Part 2

Conflicts of Interest

References

About this Document

Disclaimer

Creative Commons License

Related Info Sheets

Depression in Children and Youth: Information for Parents and Caregivers

Patient Handouts

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Depression in Children and Youth: Information for Parents and Caregivers

What is Depression? It is normal for children and youth to feel sad from time to time. But this sadness doesn’t stop them from going on with their everyday activities. And it goes away on its own. Depression, on the other hand, is a sadness so severe that it interferes with everyday life. Typical symptoms of depression (aka clinical depression, or major depressive disorder) are: Feeling sad, worried, irritable or angry. Lack of enjoyment in life, or troubles enjoying anything Feeling hopeless and worthless, Troubles coping with everyday activities at home, school, or work Problems ...

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What medications are used to treat depression? Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine. &nb...

More...

What medications are used to treat depression?

Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:

Fluoxetine (Prozac)
Citalopram (Celexa)
Sertraline (Zoloft)
Paroxetine (Paxil)
Escitalopram (Lexapro).

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications.

What are the side effects?

Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

Headache, which usually goes away within a few days.
Nausea (feeling sick to your stomach), which usually goes away within a few days.
Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.
Agitation (feeling jittery).
Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

Dry mouth.
Constipation.
Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
Blurred vision, which usually goes away quickly.
Drowsiness. Usually, antidepressants that make you drowsy are taken at bedtime.

People taking MAOIs need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some medications, including decongestants and over-the-counter cold medicine.

Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOIs should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken?

People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked," on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by NIMH found that if a person with difficult-to-treat depression did not get better with a first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).2,3

Are herbal medicines used to treat depression?

The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health conducted a clinical trial to determine the effectiveness of treating adults who have major depression with St. Johns wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI, and one-third took a placebo, or "sugar pill." The people did not know what they were taking. The study found that St. John's wort was no more effective than the placebo in treating major depression.4 A study currently in progress is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can dangerously interact with other medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. Johns wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

FDA warning on antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects, especially in young people. In 2004, the FDA looked at published and unpublished data on trials of antidepressants that involved nearly 4,400 children and adolescents. They found that 4 percent of those taking antidepressants thought about or tried suicide (although no suicides occurred), compared to 2 percent of those receiving placebos (sugar pill).

In 2005, the FDA decided to adopt a "black box" warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24.

The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. To find the latest information visit the FDA website.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.5 The study was funded in part by NIMH.

Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

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NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

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I am writing to give you an update regarding your student, who having Mood Problems, i.e. Depression. Accommodations are essential for this student to function in the academic program. Feel free to adapt this list, however, here is a general list of suggested accommodations. Instructional Strategies Interpersonal interventions Fe...

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I am writing to give you an update regarding your student, who having Mood Problems, i.e. Depression.

Accommodations are essential for this student to function in the academic program. Feel free to adapt this list, however, here is a general list of suggested accommodations.

Instructional Strategies

Interpersonal interventions

Feeling connected to people is particularly important with mood problems, particularly because students with mood problems youth tend to withdraw from others. Help connect the student to supportive peers, and offer opportunities to participate in organized school activities such as clubs, sports.
Make a special contact with the student each day. Maybe a specific greeting at the door followed by a question about something that has been of interest to the student.

Build strength and resiliency by reinforcing successes and positives

What times has your student been successful at things in the past? What are your student’s strengths? Tell the student about any positives.
Being successful and accomplishing tasks increases self-esteem so find ways to ensure the student has chances to achieve, even at his/her lower energy level and reduced ability to concentrate.

Reduce workload

Mood problems such as depression may lower the student’s ability to work. Consider temporarily reducing the academic expectations and workload. Just like one might modify job tasks for a worker with back injury, it is important to modify tasks for a student with mood problems.

Give more time

Students with mood problems tend to have problems with attention and concentration. Give more time, break assignments into smaller pieces, offer extra help in setting up schedules or study habits, or pair the student with others who express an interest in helping.

Coping / Stress Breaks (aka ‘Chill Time’) (Try to avoid the term ‘Time Out’ because for some students this has a negative connotation…)

Expressing stress -- Come up with a system to help the student identify when s/he is getting overwhelmed, and be able to communicate that to the teachers.
For example, using a 5-point scale, where 1 is no problems, and 5 is being stressed and overwhelmed

Create a safe space

Designate a “chill out zone” / “safe place” where the student can go if s/he is feeling overwhelmed. By giving the student the ability to calm down at school, this will lessen the chances that the student will end up leaving the school.
Talk ahead of time privately with the student, and set up some signal or cue so that the student can leave the class if the student is getting overwhelmed.

Set clear expectations

Many students have anxiety because they are uncertain about their teacher’s expectations. To help with this, provide the student with explicit guidelines for assignments. In addition, explicit guidelines for assignments help mitigate the negative impact of anxiety and depression symptoms on executive functioning. (Executive skills help a student to regulate his or her behavior. Through the use of these skills a student can plan and organize activities, sustain attention, and persist to complete a task.)

Classroom Education / Anti-Stigma

Consider having a lesson about mood problems, in order for other students to know about anxiety so that they can understand what the student with mood problems is going through. Do not single out the student with mood problems, but make the lesson a about mood problems in general. For more information, the CMHA has an excellent curriculum here www.cmha.ca/highschoolcurriculum/
Prevent stigma / teasing: Deal immediately with any negative behavior by peers toward this student
Provide copies of classroom notes to cover absences due to anxiety, as the student may be missing classes due to anxiety, or doctor’s appointments.

Coping Plan

Involve the student in coming up with a coping plan, whose elements might include:
Student’s strengths
Potential problems or issues
Strategies and solutions to try

Suicidal ideation and crises

Although depression does get better in the vast majority of situations, youth with mood problems may become overwhelmed to the point where they may feel passively suicidal (“Life isn’t worth living”), or actively suicidal (“Life isn’t worth living, and I’m going to do something to end my life.”)
Learn about local resources (i.e. where you might get professional help) in case there are concerns about suicidality. Most likely, your school board already has a policy and procedure in place for such urgent situations.

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Examples of Common Workplace Accommodations Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations: Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be f...

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Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

Assume that the employee’s request for accommodation is made in good faith.

In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

Maintain records of the request and steps taken to deal with the request.

Maintain and respect confidentiality issues.

Pay the cost of the accommodations, including fees for any medical certificates required.

Request only information that is directly related to developing an appropriate accommodation.

Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

If requested, provide supporting documentation or medical certificates.

Meet all relevant job requirements and standards once the accommodation has been provided.

Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp

+ Suggest External Link

External Links

(Teen) Mental Health Literacy

Website providing information and resources about teen mental health. Formerly known as Teen Mental Health with Dr. Stan Kutcher and colleagues.