Major Depressive Episode

DSM IV Criteria

A) Five (or more) of the following symptoms have been present during the same 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

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations

1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4) insomnia or hypersomnia nearly every day
5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B) The symptoms do not meet criteria for a Mixed Episode

C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)

E) The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

6-item Kutcher Adolescent Depression Scale (KADS)

Over the last week, how have you been "on average" or "usually" regarding the following items:

1)                   low mood, sadness, feeling blah or down, depressed, just can't be bothered.

a)                  hardly ever

b)             much of the time

c)             most of the time

d)                 all of the time

2)                  feelings of worthlessness, hopelessness, letting people down, not being a good person.

a)             hardly ever

b)             much of the time

c)             most of the time

d)            all of the time

3)                  feeling tired, feeling fatigued, low in energy, hard to get motivated, have to push to get things done, want to rest or lie down a lot.

a)             hardly ever

b)             much of the time

c)             most of the time

d)                 all of the time

4)                  feeling that life is not very much fun, not feeling good when usually (before getting sick) would feel good, not getting as much pleasure from fun things as usual (before getting sick).

a)             hardly ever

b)             much of the time

c)             most of the time

d)            all of the time

5)                  feeling worried, nervous, panicky, tense, keyed up, anxious.

a)             hardly ever

b)             much of the time

c)             most of the time

d)            all of the time

6)                  Thoughts, plans or actions about suicide or self-harm.

a)             no thoughts or plans or actions

b)             occasional thoughts, no plans or actions

c)             frequent thoughts, no plans or actions

d)            plans and/or actions that have hurt

Scoring  of the 6-item Kutcher Adolescent Depression Scale (KADS):

In every item, score:

a)                  = 0

b)                 = 1

c)                  = 2

d)                 = 3

then add all 6 item scores to form a single Total Score.

Interpretation:

Total scores at or above 6 suggest 'possible depression' (and a need for more thorough assessment).

Total scores below 6 indicate 'probably not depressed'.

© 1999-2005 Mood Disorders Association of Ontario. All rights reserved (with exceptions noted).

Ways to Help Prevent Suicide in Depressed Adolescents

(Adapted from materials prepared by familyaware.org)

1. Encourage adolescents and parents to make their homes safe. In teens ages ten to nineteen, the most common method of suicide is by firearm, followed closely by suffocation (mostly hanging) and poisoning.  All guns and other weapons should be removed from the house, or at least locked up. Other potentially harmful items such as ropes, cords, sharp knives, alcohol and other drugs, and poisons should also be removed.

2. Ask about suicide. Providers and parents should ask regularly about thoughts of suicide.  Provides should remind parents that making these inquiries will not promote the idea of suicide.

 

3.  Watch for suicidal behavior.  Behaviors to watch for in children and teens include:

·        expressing self-destructive thoughts

·        drawing morbid or death-related pictures

·        using death as a theme during play in young children

·        listening to music that centers around death

·        playing video games that have a self-destructive theme

·        reading books or other publications that focus on death

·        watching television programs that center around death

·        visiting internet sites that contain death-related content

·        giving away possessions

3. Watch for signs of drinking. If a child has depression, feels suicidal, and drinks a lot of alcohol, the person is more likely to take his or her life. Parents are usually unaware that their child is drinking. If your child is drinking, you need to discuss this with your child and the clinician.

4. Develop a suicide emergency plan. Work with patients and parents to decide how do proceed if a child feels suicidal.  It is important to be specific and provide adolescents with accurate names, phone numbers and addresses.

Active Monitoring

Given the tumultuous nature of adolescence, the episodic nature of depression, and the mixed data regarding response to even the most evidence-based treatments, immediate treatment of a new-onset mild to moderate depressive episode may not always be indicated.  However, rather than watchfully waiting to see if depressed adolescents improve, this guideline advocates active monitoring instead.  This subtle distinction in word choice is meant to discourage a passive approach and emphasize all of the important things a primary care physician can do BEFORE initiating a formal psychotherapeutic or pharmacological treatment.  The following list contains only some of the various ways in which primary care physicians and/or care managers can actively engage with depressed youth while monitoring for changes in their clinical exam:

• Schedule frequent visits
• Prescribe regular exercise and leisure activities
• Recommend a peer support group
• Review Self-Management goals
• Follow-up with patients via telephone
• Provide patients and families with educational materials

Education of patients and family members (and -- when indicated and informed consent is obtained -- teachers and/or peers) is a crucial part of active monitoring that can broaden an individuals support network and improve the chances that clinical changes are observed.  Please see the parent and adolescent educational materials sections for resources that may be copied for distribution to your own patients and families. 

It is important to note that while active monitoring does not have to be continued indefinitely, it should be continued even after individuals improve.  If, after a pre-determined amount of time, your patient’s depression fails to improve or clinically worsens, an evidence-based treatment is indicated.

Adolescent Depression Treatment Monitoring Flowsheet