Screening for Depression and Suicide in Children

Prevention is critical in the management of childhood depression and suicide. Depression is a common mental health disorder in children and adolescents. The prevalence is around 3% in younger children and about 8% in adolescents. The prevalence of depression and mental health disorders is increasing. Some studies have found higher rates in females compared to males. Like other mental health conditions, depression is often underreported and underdiagnosed in children. There is a wide range of clinical severity and presentations for childhood depression. Major depressive disorder (MDD) is associated with functional impairment in the crucial phase of childhood development. Less than half of children diagnosed with MDD receive appropriate treatment and referrals. It is among the most important factors that contribute to suicide in children. Suicide is the second most common death in adolescents. Suicidal deaths have surpassed the deaths due to motor vehicle accidents. In 2019, almost one in ten high school students reported at least one suicide attempt. About 7 in 100,000 children die of suicide. More than 80% of children who attempt suicide are not identified by pediatricians in a routine visit months before the suicide attempt. Hence, depression and suicide in children are major global public health problems. Suicide is among the most common sentinel events. In 2019, the Joint Commission issued recommendations for national patient safety goals on suicide prevention. It includes environment risk assessment, validated suicide risk assessment tools, and safe discharge planning. The US Department of Health ad Human Services has targeted decreasing suicide rates as one of the priority areas in the Healthy 2030 plan. The American Psychiatry Association’s Diagnostic and Statistical Manual of Mental disorders (DSM 5) has a set of clinical criteria for the diagnosis of MDD to be met over a period of at least two weeks. Some of these clinical symptoms include sad mood, lack of interest, weight change, sleep disturbances, fatigue, and psychomotor agitation or retardation. It can lead to significant social and school functioning. Risk factors for childhood depression are multiple. They include a positive family history of depression, previous history of depression or suicide, concomitant mental health disorders, chronic medical illnesses, obesity or body image disorders, female gender, child abuse or neglect, adverse childhood experiences, poor school performance, loss of a family member or loved one, low socioeconomic status, uncertainty about sexual orientation, break up of a romantic relationship, family problems. Younger age of adverse childhood experiences (ACE) and multiple ACEs lead to more severe depression. Children with depression can have concomitant mental disorders like anxiety, conduct or oppositional defiant disorder, substance use somatic disorders. Early diagnosis and treatment of depression in children are paramount. Management includes counseling, antidepressant medications, psychotherapy (cognitive behavioral therapy and interpersonal therapy), and electro convulsant therapy. The treatment should involve shared decision-making with the patient and family. Educating primary care providers about brief cognitive behavioral therapy and family therapy skills improves the treatment outcome, and as a result, more families will seek mental health treatment for their children.