AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Dysthymic disorder may be diagnosed in children and adolescents when a pervasive depressed or irritable mood is present for at least 1 year. Two additional symptoms of depression must also be present for most of the day at least half of the time during that year to make the diagnosis. Depressive symptoms typical in dysthymic disorder include diminished or increased appetite, insomnia or hypersomnia, low energy or fatigue, poor self-esteem, difficulties with concentration or decision-making, and feelings of hopelessness.

Pathophysiology

Several neurotransmitter systems have been hypothesized to be involved in the emergence of depressive disorders, including the noradrenergic, serotonergic, cholinergic, and dopaminergic systems. Studies of adults with depression have shown blunted responses of cortisol secretion in response to serotonergic challenges. One study's results suggested that depressed children may also show a blunted cortisol secretion response when challenged with serotonergic agents. Studies in adults have also shown that there are lower levels of the serotonin metabolite, 5-hydroxyindoleacetic acid (5-HIAA), in the cerebrospinal fluid (CSF) of both those who attempt suicide and those who complete it. Studies have shown that children with depressive disorders may have blunted growth hormone responses when challenged with adrenergic agents such as clonidine (Catapres).

Among adults with depression, there is evidence of sleep abnormalities including reduced slow wave (delta) sleep, diminished latency to rapid eye movement (REM) sleep, increased REM density, and increased awakening during the night. Sleep disturbance studies in children and adolescents experiencing depression have been more variable. There is some evidence that children and adolescents with recurrent depression may have shorter REM latency during the period of depression as well as during periods of remission.

Frequency

United States

Point prevalence rates from 0.6-1.7% in children and 1.6-8.0% in adolescents have been reported.

International

Rates in Europe generally correspond with US rates. Developing countries have higher prevalence of minor psychiatric illnesses in general.

Mortality/Morbidity

• Mortality
  • Dysthymic disorder increases the risk for development of major depressive disorder, with its concomitant possibility for suicidal thoughts and suicide attempts. Children who have dysthymia along with an exacerbation of depressive symptoms, including recurrent suicidal ideation, may be diagnosed with major depression in conjunction with dysthymic disorder. Suicidal thoughts are not uncommon in preadolescent children with depression, although attempts are less common than in adolescents or adults and are less likely to be lethal. Community studies have shown 8.9% of preadolescent depressed children express suicidal ideas and 3% make threats or mild attempts.
  • Among US adolescents, suicide is the third-ranking cause of death (rate of 7.4 per 100,000 for the age range 15-19, rate of 1.2 per 100,000 for the age range 10-14, rate of 4.3 for the age range 10-19), after accidents and homicide. Nearly one fourth of high school students in the United States report having considered suicide, approximately 18% acknowledged more serious intent by making a specific suicide plan, and nearly 8% have attempted suicide, with almost 3% requiring medical attention for associated injuries.

    Suicide rates vary according to sex and ethnicity, with American Indians/Alaska natives having roughly twice the rate of death by suicide than do whites, who have a rate roughly twice that of blacks and Asians/Pacific Islanders (8 per 100,000 vs/ 4.7 vs 2.5, respectively). Males outnumber females in terms of death from suicide in all ethnic groups, with ratios ranging from 3:1 in Asian/Pacific Islanders to 4:1 in Native Americans to 5:1 in whites to almost 6:1 in blacks. The gender differences parallel those in adults, where men are more likely than women to die from suicide attempts due to use of more lethal means. While suicidality is not a predominate symptom in dysthymia, mood disorders are considered a spectrum disorder, and suicidal tendencies should be carefully assessed in all patients with depressive symptoms.

• Morbidity
  • Dysthymic disorder causes severe and prolonged social, interpersonal, and academic dysfunction. Children whose parents have depressive disorders are up to 3 times more likely to develop a mood disorder. In addition to the academic, behavioral, and peer relationship problems associated with childhood mood disorder, unstable homes and exposure to stressful life events increase the risk for dysfunction even further.
  • Childhood dysthymic disorder is associated with increased risk for subsequent major depressive disorder and bipolar disorders and less likely but significant increased risk for substance use disorders and anxiety disorders. Approximately 70% of pediatric patients with dysthymic disorder will develop a superimposed major depressive disorder within 5 years. Fifty percent of pediatric patients with dysthymic disorder have other psychiatric disorders as well, including 40% with anxiety disorders, 30% with conduct disorder, 24% with attention deficit/hyperactivity disorder (ADHD), and 15% with elimination disorders (ie, enuresis, encopresis). Approximately 15% of pediatric patients with dysthymic disorder have 2 or more comorbid disorders.
  • Comorbid diagnoses increase the risk for recurrence of depression, lengthen the duration of depressive episodes, increase the risk of suicide, and increase the rate of utilization of mental health services. Individuals with additional psychiatric disorders have poorer outcomes, poorer response to treatment, and more severe social impairment.
  • Depressed children are more likely to use tobacco, alcohol, and other substances in adolescence and adulthood. Of course, increased mortality and morbidity are associated with these behaviors as well.

Race

What few data exist suggest that prevalence of dysthymia among ethnic minority pediatric populations is similar to or lower than the prevalence in white pediatric populations in the United States.

Sex

Major depressive disorder has a male-to-female prevalence ratio of 1:1 in prepubertal children and 1:2 in adolescents. In children, dysthymic disorder appears to occur equally in both sexes. Authors have speculated as to why rates of depression go up in adolescence, especially in girls. Biological, psychosocial, and cognitive factors probably contribute. One hypothesis is that girls are more likely to deal with stressors in a ruminative and openly expressive way, in addition to entering puberty earlier than boys (with the concomitant psychosocial and biological consequences). As adolescents, females are more likely to be exposed to sexual abuse, worry about their body image, and feel pressure to conform to restrictive social images than are males.

Age

Studies of depression in the pediatric population show a rise in frequency with age. Rates and gender ratios approach adult levels with older adolescents. These data are subject to interpretation based on changing diagnostic criteria for depression over time.

• Years ago, depression was not diagnosed in childhood. According to the Freudian concept that depression is based on the individual's response to loss, children were thought to be incapable of depression because their psychosexual development was thought to be too immature to produce it.
• In the 1960s, it was suggested that children suffer "masked depression"; that is, that typical depressive symptoms are expressed as equivalents such as hyperactivity, learning disabilities, and encopresis. However, scrutiny of clinical reports over the last 100 years leads to the conclusion that the same core symptoms of depression observed in adolescents and adults also occur in children.
• It is now widely accepted that children express depressive symptoms in a manner consistent with their developmental level, including their ability to articulate their feelings and reflect upon their mood. Thus, the frequency of various depressive symptoms in children are developmentally linked; depressed prepubertal children may manifest more somatic complaints, self-esteem difficulties, and sad facial expression compared to adolescents and adults. The core depressive symptoms in affective disorders can be shown to be present in children as well as in adults if the assessment tool used is developmentally sensitive.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The clinical history is crucial in making the diagnosis of this disorder. Behavioral assessment in pediatric patients must take into account the patient's current developmental stage and often includes information from additional sources, mainly parents and teachers.

• Diagnostic criteria taken from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), American Psychiatric Association (APA), are listed below.
• • A - Depressed (or irritable) mood for most of the day for more days than not as indicated by subjective account or observation by others for at least 1 year. (In children, parental report may emphasize behavioral difficulties expressing depression, whereas the child can give a better account of internalizing symptoms, including suicidal ideation.)
  • B - Presence, while depressed, of 2 (or more) of the following: (1) poor appetite or overeating, (2) insomnia or hypersomnia, (3) low energy or fatigue, (4) low self-esteem, (5) poor concentration or difficulty making decisions, and (6) feelings of hopelessness
  • C - During the 1-year period of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.
  • D - No major depressive episode has been present during the first year of the disturbance; that is, the disturbance is not better accounted for by chronic major depressive disorder or major depressive disorder in partial remission.
  • E - There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
  • F - The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.
  • G - The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hypothyroidism).
  • H - The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Some symptoms of depressive disorders are more common in children than in adults. For example, irritability, social withdrawal, and somatic complaints (unexplained general medical complaints) are more likely to be observed in children. On the other hand, hypersomnia and psychomotor retardation are more common in adults. Children, particularly younger children, may display aggressive behavior and psychomotor agitation as aspects of dysthymic disorder.
• Other symptoms associated with dysthymic disorder but not included in the formal diagnostic criteria are anger, feelings of being unloved, self-deprecation, anxiety, and disobedience. A considerable overlap of symptoms exists between dysthymic disorder and major depressive disorder, and the relationship between them is the subject of ongoing debate. Dysthymic disorder and major depressive disorder differ in terms of both chronicity and pervasiveness. In addition, the chronic course of dysthymic disorder can contribute to academic, social, and behavioral disruption, with profound effects on psychological and educational development. Children and adolescents with dysthymic disorder may develop more acute and intense depressive symptoms sufficient to meet criteria for major depression.

Physical

A thorough physical examination is important to rule out medical illness as a cause of symptoms.

Causes

Depressive disorders are etiologically heterogeneous. Genetic, biological, psychological, and environmental factors contribute to depression. Much of the following discussion applies to many depressive disorders including dysthymic disorder.

• Genetic factors: Such factors are considered to account for approximately 50% of the variance in the transmission of depressive disorders. Children of parents who are depressed are 3 times more likely to experience a depressive episode than children of parents who are not depressed. Twenty to 45% of parents of depressed children have depressive disorders. However, the specificity of these findings is clouded by the fact that psychopathology, in general, is more common in parents of depressed children, and, in general, depressed parents produce children with other psychopathology as well.

  Transmission of depression in families may occur by means of nongenetic pathways; environmental stressors increase in families with depressed members. Temperament modulates the expression of genetic variance. Temperament is defined as a long-standing behavioral style, mostly inherited, evident early in life, stable during time, and observable in a variety of settings. Some temperamental patterns are likely to make individual children more vulnerable to depression and other disorders.

• Biological factors: The biological substrate of mood disorders is the basis of pharmacologic treatment. As noted above, several neurotransmitters are likely to contribute to mood problems, with noradrenergic, serotoninergic, cholinergic, and dopaminergic systems as candidates. The biogenic amines, norepinephrine and serotonin, regulate mood, sleep, appetite, and activity; they are implicated in dysthymic disorder and are modified by the current antidepressant drugs. Neuroendocrine abnormalities (blunted growth hormone, hypothalamic-pituitary-adrenal problems, hypothalamic-pituitary-thyroid patterns) are thought to be related to the activity of the above-mentioned neurotransmitters; the effects are heterogenous. Sleep architecture changes have been found in depressed adolescents, but inconsistently. Biological measures cannot be used to rule in or out particular mood disorders. It is hypothesized that maturational differences in neurotransmitter systems account for psychobiological differences observedin
  pediatric and adult depressive disorders.
• Psychological factors: Three main theories have been studied in the etiology of depressive disorders. Psychoanalytic theory relates the origin of depression to loss of love-objects. Behavioral theories focus on the concept of learned helplessness. Cognitive behavioral theories suggest that depressive disorders are related to negative appraisals of the self and of one's competence and abilities. All of the above models suggest that a person vulnerable to depression responds to adversity by withdrawal and inaction.
• Environmental factors: Life events and family functioning are considered to be potential risk factors or protective factors in the development of dysthymia and other depressive disorders. Families with poor coping abilities, low levels of communication within the family, high levels of intrafamilial conflict, and inconsistent emotional response teach children maladaptive affective regulation. If traumatic life events occur, children reared in chaotic environments have increased vulnerability to depressive outcomes. Studies have shown that negative life events are more likely to be associated with the onset of emotional disorders if maternal distress and a poor mother-child relationship are present. Contrariwise, good parent-child and good family relationships can mitigate the effects of traumatic life events.
• A complex relationship is likely to exist between genetic predisposition, disrupted attachments, internal psychological representations and attributions, dysfunctional social interactions, risk and protective factors, and melancholic endocrine changes in the etiology of dysthymic disorder and depression.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Mood disorder due to a general medical condition
Alcohol-induced mood disorder
Substance-induced mood disorder
Alcohol or substance use or abuse
Personality disorder
Schizoaffective disorder
Bereavement
Adjustment disorder with depressed mood
Adjustment disorder with mixed anxiety and depressed mood
Depressive disorder not otherwise specified
Seasonal affective disorder
Growth retardation
Language disorder: mixed
Language disorder: phonology
Language disorder: receptive
Language disorder: stuttering
Somatoform disorder: hypochondriasis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Perform lab studies only when the history and physical examination suggest their relevance.

Imaging Studies

• Few, if any, studies use either structural (ie, CT scan, MRI) or functional (ie, positron emission tomography [PET], single-photon emission computed tomography [SPECT], magnetic resonance spectroscopy [MRS]) imaging in the diagnosis of dysthymia in pediatric patients.

Other Tests

• Assessment of dysthymic disorder in children can be accomplished in several ways. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends a comprehensive mental health diagnostic evaluation as the single most useful tool in the diagnosis of depressive disorders. Standardized diagnostic interviews, conducted by clinicians or lay examiners, often are used in research settings and have been studied psychometrically. Self-report questionnaires have been developed, but they mainly serve as screening tools and may not reflect diagnostic criteria for dysthymic disorder. Likewise, ratings by teachers, parents, and peers may be helpful as part of the overall assessment of the depressed pediatric patient but, of course, would not be sufficient to make a diagnostic determination.
• According to the AACAP, a comprehensive mental health diagnostic evaluation consists of separate and/or conjoint interviews by a trained clinician with the patient and his or her parents or caregivers. Contact with other informants (eg, teachers, primary care physicians) is helpful. A mental status examination, modified as necessary for the patient's developmental age, should be part of the assessment. Physical examination and, as noted above, lab tests as suggested by the physical examination, often are helpful in ruling out general medical conditions that may produce depressive symptoms. In addition, the mental health professional should obtain information about the following:
• • Comorbid psychiatric diagnoses
  • Psychosocial problems
  • Academic problems
  • Recent and historical negative life events
  • Family psychiatric history
  • Level of social support
  • Medical history
  • Current and past use of medications
  • Substance use: An assessment of global functioning will be useful in determining current impairment, if any, in life tasks.
• The Child Assessment Schedule (CAS), administered by a trained clinician, reliably and validly assesses dysthymic disorder, as does the Interview Schedule for Children (ISC). Another widely used research scale, the Schedule for Affective Disorders and Schizophrenia in School-Age Children (K-SADS), does not assess dysthymia as a separate diagnostic category. Other structured interview schedules for use with lay interviewers do not differentiate dysthymic disorder from generalized depression.
• Self-report measurement scales, such as the Children's Depression Inventory (developed from the Beck Depression Inventory) and the Reynolds Child and the Reynolds Adolescent depression scales, can be very helpful when used as screening tools. They have the advantage of also providing a means of assessing treatment response when used as repeated measures. Indications of depression on self-report scales should be followed with a more thorough assessment by a physician or mental health professional. Multiple informants and multiple methods (eg, self-report, interview, observations) will give the most thorough picture of the extent of depression and the level of impairment of functioning.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Various types of psychotherapy (psychodynamic, cognitive-behavioral, interpersonal, family therapy) have been the mainstay of treatment of dysthymic disorder in children and adolescents. Recently, increasing emphasis has been placed on psychopharmacology in depressed pediatric patients. However, most of the recommendations for treatment with either psychotherapy or drugs are based on the adult literature. At the time of writing, controlled studies of different treatment strategies for major depressive disorder in the pediatric population have only begun to be conducted. Given the experience with adult patients that effective treatments for major depression also work for dysthymic disorder, the results from these current studies can probably inform treatment planning for children with dysthymic disorder.

Integration of psychotherapeutic treatment and psychopharmacologic treatment is typical in the adult population suffering from dysthymic disorder. In adults, studies have shown that tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) are helpful when administered at the same dosages used in the treatment of major depressive disorder. However, most of the studies of treatment in the pediatric population have used psychotherapy as the primary treatment. Very few studies exist on the use of pharmacotherapy alone or on combined pharmacotherapy and psychotherapy with pediatric dysthymic patients.

The American Academy of Child and Adolescent Psychiatry, in the absence of further research, recommends that interventions that have been found efficacious for major depressive disorder should be used with dysthymic children and adolescents. Because of the chronicity of dysthymic disorder (mean episode duration 3-4 years for community samples, duration at least 1 year to make the diagnosis), intense and long-term treatment may be necessary. This is particularly challenging given the arbitrary limits on insurance coverage for mental health diagnoses.

• Psychotherapy is used to teach patients and their families to cope with stress (both current and historical), improve social skills and self-concept, understand themselves and their family, and deal with interpersonal and social conflict. In addition, it can help patients deal with the familial, academic, and occupational problems associated with depression. Psychodynamic psychotherapy, interpersonal therapy, cognitive-behavioral therapy, behavior therapy, family therapy, supportive psychotherapy, and group psychotherapy have been used with depressed pediatric patients. Several factors appear to be related to the effectiveness of psychotherapy, including the following:
  • Age at onset of depression
  • Severity of depression
  • Presence of comorbid psychiatric disorders
  • Presence of or lack of support
  • Parental psychopathology
  • Significant family conflict
  • Exposure to stressful life events
  • Socioeconomic
    status
  • Quality of treatment
  • Therapist's expertise
  • Motivation of both patient and therapist
• Psychodynamic psychotherapy, informed by psychoanalytic thinking, has as its goals helping patients understand themselves, identify feelings, improve self-esteem, change dysfunctional patterns of behavior, interact more appropriately with others, and manage past and ongoing conflicted relationships.
• Interpersonal therapy focuses on interpersonal roles and difficulties. Grief, disputes, and role transitions are among issues that may be dealt with in individuals with dysthymic disorder. Improved interpersonal relationships may help lessen the possibility of relapse after treatment.
• Cognitive-behavioral therapy deals with the cognitive distortions present in the patients' views of themselves, others, and the world. Cognitive-behavior therapy systematically examines and counteracts these distortions, which contribute to the maintenance of depression. In the pediatric population, of course, intellectual and conceptual development may limit the usefulness of this technique.
• Supportive psychotherapy offers a nuturing environment for the expression of affect. However, in one study of adolescents, it has been shown to be less effective than cognitive-behavior therapy.
• Group psychotherapy, using a variety of the above techniques, can be effective and efficient.

Consultations

Psychotherapeutic treatment generally requires the pediatrician to make a referral to a trained mental health clinician. Child clinical psychologists, child and adolescent psychiatrists, behavioral-developmental pediatricians, child- trained clinical social workers, and professional counselors are resources for the pediatrician who encounters dysthymic patients. Given the paucity of data in children showing clear safety and efficacy of pharmacologic intervention in children with dysthymic disorder psychosocial interventions are often tried before psychopharmacological treatment is considered.

Activity

Encouragement of developmentally appropriate play, physical exercise, and pleasurable activities are appropriate for children with anhedonia. Physical exercise has been shown to improve mood. Active play or sports (if psychologically supportive, rather than an opportunity for criticism) can accomplish these aims.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

According to the American Academy of Child and Adolescent Psychiatry Practice Parameters, few studies exist to inform the use of antidepressant medication in children with dysthymic disorder. Studies of adult dysthymic patients have shown that TCAs, SSRIs, and MAOIs are effective for the treatment of dysthymic disorder at the same doses effective for major depressive disorder.

"In anticipation of further research, interventions described for children and adolescents with major depressive disorder are recommended for the treatment of children and adolescents with dysthymic disorder," states the AACAP. However, the US Food and Drug Administration (FDA) has approved only a handful of the multiple drugs in the first 2 of the above 3 classes for use in depression (or for other indications) in children and adolescents. Since most medications administrated to children have not been extensively studied in the pediatric population, information below is given with the understanding that this use reflects current practice among child and adolescent psychiatrists. As a patient's age approaches adolescence, the physician can be more confident that the treatment is likely to be as effective as it is for the disorder in adulthood.

Current consensus is that SSRIs are preferred greatly over the other classes of antidepressants. The adverse effect profile is less prominent, promoting compliance. SSRIs also are much safer, without the risk of cardiac arrhythmia observed in TCAs. Such a risk is especially pertinent in overdose, and suicide risk always must be considered in the treatment of a child or adolescent with a mood disorder.

Drug Category: Selective serotonin reuptake inhibitors (SSRIs)

Antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. Inhibits CNS neuronal uptake of serotonin (5HT). May also have a weak effect on norepinephrine and dopamine neuronal reuptake.

Note: Increasing controversy exists over the use of SSRIs in the pediatric population. In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder (not dysthymic disorder). This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. Nonetheless, the FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and, thus, could not be linked to drug treatment (see Complications, Medical/Legal Pitfalls).

In March 2004, the FDA issued a public health advisory regarding several antidepressant medications, partly in response to their use in the pediatric population. For more information, see the FDA advisory statement on worsening depression and risk of suicidality with antidepressant drugs). After the initiation of medical treatment, physicians are advised to closely monitor for worsening depression or suicidality and for signs of mania or hypomania development. Furthermore, the FDA advisory specifically states that health care providers should instruct patients, families, and caregivers to be alert for the emergence of suicidality, worsening depression, agitation, irritability, and other symptoms (eg, anxiety, panic attacks, insomnia, hostility, impulsivity, akathisia, hypomania, mania) and to immediately report such symptoms to the health care provider.

In October 2004, the FDA issued a Public Health Advisory intended to warn the public about the risks of increasing suicidality among adolescents and children treated with antidepressants. These efforts included requiring a "black box" warning on medication labeling directed to prescribers and development of patient information materials to inform consumers of the potential risks of suicidal behavior in depressed pediatric patients. For more information, see the FDA statement on safeguards for children treated with antidepressants.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the used of antidepressants. This is the largest study to date to address this issue.

Currently, evidence does not exist to associate OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Note that fluoxetine (Prozac) is the only medication approved by the FDA to treat depression in children aged 7 years and older. Other medications are used off-label.

The FDA's recommendations are sound in the treatment and monitoring of all patients with mood disorders, whether or not medication is used, as noted elsewhere in this article. Because treatment response and the course of the illness are variable, ongoing monitoring for increasing severity of the illness and development of more intense symptoms is wise.

Physicians are advised to be aware of the above information and use appropriate caution when considering treatment with antidepressant medications in the pediatric population.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care generally is not necessary for the treatment of dysthymic disorder. If major depression develops with suicidal ideation, then inpatient care may be urgently needed.

Further Outpatient Care

• Given the chronic nature of dysthymic disorder, ongoing psychotherapeutic and/or psychopharmacologic care may be necessary to foster sustained remission and modification of maladaptive coping. Termination of cognitive-behavioral therapy and interpersonal therapy, when studied in the treatment of major depression in the pediatric population, has resulted in a significant relapse rate on follow-up care, suggesting the need for maintenance therapy.

In/Out Patient Meds

• Dysthymic disorder rarely is treated by itself on an inpatient basis. Outpatient treatment is mainly via psychotherapy, with occasional use of medications as noted above.

Transfer

• Psychotherapeutic treatment for children with mood disorders is best done by a clinician who is trained in the area of psychotherapy in pediatric populations. Transfer of care to a child and adolescent psychiatrist, behavioral-developmental pediatrician, clinical pediatric psychologist, social worker, or family therapist is recommended. When medication is being considered, a psychiatrist or behavioral pediatrician will be required.

Deterrence/Prevention

• Very few studies have been published on the prevention of depressive disorders in general in children and adolescents. Given the lengthy course of dysthymic disorder, prevention and early intervention are key to minimizing suffering and functional impairment.
• Dysthymic disorder often is followed by recurrent major depression; prevention and early treatment of dysthymic disorder could help to prevent this more serious condition, as well as other potential future comorbidities such as substance abuse and school failure.
• The few studies that have been conducted show that group cognitive-behavioral therapy, together with relaxation training and group problem-solving therapy, may prevent recurrences of subclinical depression for many months posttreatment.
• Although long-term data are unavailable, brief family-based educational interventions also have helped prevent mood disorders in children at risk because of parental depression.

Complications

• Comorbid conditions frequently accompany dysthymic disorder. Such conditions need treatment as well, because they may influence the maintenance and recurrence of depression. Anxiety symptoms often coexist with depressive disorders. Early onset dysthymic disorder is associated with an increased risk of subsequent major depressive disorder and substance abuse.
• The presence of a comorbid externalizing psychiatric disorder (eg, conduct disorder, oppositional disorder, ADHD) delays recovery from dysthymia, suggesting that these conditions should be addressed first.
• Substance abuse sometimes is a complication or coexisting disorder in depressed adolescents and should be treated if it occurs.
• Cognitive and psychodynamic psychotherapies have been shown to be effective for both depressive symptoms and anxiety symptoms, as have SSRIs.

Prognosis

• Children who experience dysthymic disorder have a mean episode length of 3 years (1 y duration is required for the diagnosis). Presence of a comorbid externalizing disorder appears to add almost 2.5 years to the episode length. Sixty-nine percent of children with dysthymic disorder had a major depressive episode within 5 years of diagnosis. The spontaneous remission rate for all patients with dysthymic disorder (adult and child) may be as low as 10% per year, but the outcome is significantly better with active treatment.

Patient Education

• Education about the long-term risks of dysthymic disorder, the role of behavioral and cognitive-behavioral interventions, and teaching of social and interpersonal skills can be helpful as adjuncts to treatment.
• For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education article, Depression.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The major medical/legal pitfall to be aware of in depressive disorders is failure to assess the intensity of depression or a lack of thorough exploration of impending suicidal plans of the patient. Failure to comprehensively assess suicidal thoughts or plans may potentially result in a patient's suicide. Although dysthymic disorder typically does not involve suicidal ideation or attempts, these patients are at increased risk for development of more severe types of affective disorders, such as major depression or bipolar disorder, which could result in severe impairment or death. Unfortunately, many patients who attempt or complete suicide have seen a health care practitioner relatively recently before their suicide attempt. Frequent and thorough assessment of depressive symptoms can potentially detect an overlooked presentation of more serious disorders.
• Adolescent patients with dysthymic disorder may develop a superimposed major depressive episode and deteriorate quickly into a more severely ill state. Such a change may be overlooked by the patient, who sometimes becomes accustomed to the chronically depressed state and may not differentiate development of an acute major depressive episode from the baseline. The emotional lability of adolescents and the intensity of their developmental state and relationships may provide sufficient stress to potentiate an impulsive suicidal act. Frequent assessment of suicidal ideation and other depressive symptoms can assist the clinician in intervening appropriately. Suicide attempts are a psychiatric emergency and should be treated as such, with intensive assessment and intervention, including hospitalization if safety of the patient cannot be ensured as an outpatient.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• AACAP. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. J Am Acad Child Adolesc Psychiatry. 1998;37:63S-83S. [Medline].
• Akiskal HS, Cassano GB, eds. Dysthymia and the Spectrum of Chronic Depressions. 1st ed. Guilford Publications;1997.
• American Psychiatric Association. Dysthymic disorder. In: DSM-IV-TR 2000: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Press;2000: 376-381.
• Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry. Nov 1996;35(11):1427-39. [Medline].
• Bostic JQ, Wilens T, Spencer T, Biederman J. Juvenile mood disorders and office psychopharmacology. Pediatr Clin North Am. Dec 1997;44(6):1487-503. [Medline].
• Brieger P, Marneros A. Dysthymia and cyclothymia: historical origins and contemporary development. J Affect Disord. Sep 1997;45(3):117-26. [Medline].
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Article Last Updated: May 23, 2006