Author: Nancy R. Terry http://www.medscape.com/viewarticle/709276?src=mp&spon=17&uac=128682BJ
A new study reports that children as young as 3 years can have major depression disorder (MDD) and that those with MDD are more likely to have recurrent depression than their age-matched counterparts.
"Has child psych gone too far with this one?" asks a family medicine physician on Medscape’s Physician Connect (MPC), a physician-only discussion group. "Or do you believe that children 2 to 4 years old can be clinically depressed and require treatment?"
The study, conducted at Washington University in St. Louis, followed more than 200 preschool children, ages 3 to 6, for up to 2 years, including 75 diagnosed as having MDD. Among initially depressed children, 64% were still depressed or had a recurrent episode of depression 6 months later.
"The skeptics — and there have been many — seem to feel that the most important issue is whether depressed preschoolers grow into depressed children, adolescents, and adults, and this paper is the first step in demonstrating that that is, in fact, the case," lead author Joan L. Luby, MD, told Medscape Psychiatry.
How Common Is Depression in the Very Young?
"I’m not dismissing the possibility, but I can’t remember the last time I saw a preschooler with depression," says Stephen Grcevich, MD, "and I have a pretty busy child psychiatry practice." Several other psychiatrist contributors agree that they rarely, if ever, see depression in very young children.
A pediatrician with 40 years’ experience in childhood personality and behavior concurs that chronic depression in the very young must be rare. "I can only remember one child who clinically appeared and acted depressed, and that child was a Romanian orphan adopted by a US family."
"I would say I see such children because of the kind of work I do," says a psychiatrist who works with special education programs for preschoolers. "But this is like asking hematologists/oncologists if they have ever seen someone with a low white blood cell count." The psychiatrist adds that all the children in the special education programs with which he is involved have psychiatric diagnoses.
The study reported that symptoms of depression in preschool children include intense and sustained loss of interest in activities and play, changes in sleep patterns, lack of joyfulness, and guilt and shame. Dr. Luby, speaking with Medscape Psychiatry, said, "One of the things that make preschoolers harder to diagnosis is that they are inherently joyful."
Another pediatrician reflects that if depression is rare in the very young, an interesting question would be why this is the case. "Is there something about youngness that makes children more resilient, or something about growing older that makes us more vulnerable?" Intrigued, a psychiatrist replies, "For the most part, children think in the here and now, and aren’t concerned about issues of survival, and therefore, aren’t worrying about the future nor ruminating over the past. Kids don’t have much to be depressed about, unless they have been subject to neglect or abuse or abrupt loss of a parent or caregiver."
Trauma and Loss Put a Child at Risk for Depression
The Washington University study, which was designed to oversample for children at risk for depression, found that depression was most common in children whose mothers were depressed or had other mood disorders, and in children who had experienced a traumatic event, such as the death of a parent or physical or sexual abuse.
Several psychiatrist contributors comment that the study, although valuable, is only the most recent work to address the phenomenon of early childhood depression. Anaclitic depression, as described by René Spitz in the 1940s, addressed the issue of depression in children deprived of their mothers. "Orphanages disappeared in part as a result of the awareness of the catastrophic depressions that developed in young kids separated from their mothers and placed in institutions," comments a psychiatrist, "The most vulnerable age was from 6 months to 3 to 4 years."
Another psychiatrist adds, "I wonder if René Spitz’s papers on anaclitic depression and hospitalism are known to new generations of psychiatrists. I fear that DSM [Diagnostic Statistical Manual] psychiatry threw away the baby with the bath water when they did a tabula rasa of the whole psychiatric knowledge (and terminology) before 1980."
Yet another psychiatrist comments that additional studies are needed to examine whether depressed children become depressed adults. "Maybe some early behaviors do predict eventual adult depression, but I wouldn’t make the stretch that those early behaviors should then be treated as depression. More of a natural history." He suggests that a retrospective study involving adult patients who have attention deficit disorder might provide useful information.
Is Pharmacotherapy Appropriate for Depressed Preschoolers?
Several MPC contributors suggest that more important than establishing the existence of early childhood MDD is the issue of how to manage it. The Washington University study did not address questions of treatment.
"It is my opinion that every child has the right to be depressed now and then," says a neurologist. "Emotions are part of living and are important for experience and character. However, if the emotions are so labile and severe that they interfere with function, then there must be some intervention. Most of the time this can be done with counseling and behavioral management. On rare occasions, it is necessary to use a medication."
A family medicine physician takes issue with the use of medication in very young children, "I wouldn’t agree with treating this from a pharmacological perspective. It may do more harm than good."
"Psycho-environmental therapy, cognitive behavioral therapy, counseling, etc, sound good to me," says another family medicine physician. "We should save our patients, especially children, from the clutches of the pharmaceutical-industrial complex."
The neurologist replies that in certain cases pharmacotherapy may be indicated, even in the very young. "Children who have suffered brain injury or who are products of abuse and neglect or have severe perception defects, such as seen in autism, often get to the point of being a danger to themselves and to others due to poor impulse control and labile emotions. These are the children who may need a trial of medication." However, the neurologist emphasizes, "There is no absolute need for medication just because of an occasional episode of depression."
A psychiatrist agrees, "I think you will find that a good physician treating emotional and behavioral issues will only resort to medication when the indications are there."
The full discussion of this topic is available at: http://boards.medscape.com/forums/.29f56b80