Depression in children
Exam Tips
- In children, irritability and somatic complaints can be the presenting depressive phenotype; do not rely on obvious tearfulness.
- For ICD-11 style diagnosis in exams: >=5 symptoms for >=2 weeks, with at least one core affective symptom, plus functional impairment and exclusion of medical/substance causes.
- Always state a structured suicide/self-harm risk assessment and safeguarding assessment; this is a high-mark discriminator in OSCEs.
- Assess context from multiple informants (child, parent/carer, school) because symptom expression and impairment vary by setting.
- Name fluoxetine explicitly as first-line SSRI in under-18 depression when medication is indicated, and mention early suicidality monitoring.
- When discussing citalopram, score points by adding QT-prolongation caution and ECG consideration in at-risk patients.
Definition
Depression in children and young people is a clinically significant mood disorder characterised by persistent low mood or irritability, loss of interest/pleasure, and associated cognitive, behavioural, and neurovegetative symptoms causing functional impairment. In line with ICD-11, diagnosis generally requires at least 5 symptoms present most of the day, nearly every day, for at least 2 weeks, with at least one core affective symptom and exclusion of alternative medical, substance-related, or bereavement explanations.
Pathophysiology
Childhood depression is best understood using a biopsychosocial stress-diathesis model: genetic vulnerability (including familial mood disorder risk) interacts with adversity (trauma, bullying, family conflict, deprivation) and developmental factors (puberty, neurodevelopmental differences). Neurobiologically, evidence supports dysregulation of fronto-limbic circuits (reduced top-down prefrontal control of amygdala threat responses), altered reward processing in striatal pathways (anhedonia), HPA-axis hyperreactivity with chronic cortisol stress signalling, and abnormalities in monoaminergic transmission (serotonin/noradrenaline/dopamine) plus impaired neuroplasticity (e. g, reduced BDNF signalling). Sleep and circadian disruption, inflammation, substance use, and chronic physical illness can amplify these pathways and perpetuate episodes. See Figure: stress-diathesis formulation and fronto-limbic circuitry diagrams in core child and adolescent psychiatry textbooks.
Risk Factors
- Family history of depression
- Family history of other mental illness, substance misuse, or suicidal behaviour
- Personal history of depression, anxiety, or other mental health problems
- Female sex after puberty (marked rise in prevalence from early adolescence)
- Recent adverse life events (bereavement, parental separation/divorce, parental job loss, relocation)
- Family discord, poor attachment security, or high expressed emotion
- Trauma history (physical, sexual, emotional abuse or neglect)
- Bullying (including cyberbullying)
- Minority stress and discrimination (ethnic, racial, sexual minority status)
- Poverty, homelessness, refugee status, or institutional care
- Alcohol/substance misuse
- Medication effects (e. g, corticosteroids)
- Chronic physical illness (e. g, diabetes, asthma, epilepsy, inflammatory bowel disease)
- Increased academic and social pressures
Clinical Features
Symptoms
- Persistent low mood or irritability
- Markedly reduced interest or pleasure (anhedonia)
- Poor concentration or indecisiveness
- Low self-esteem, excessive/inappropriate guilt, worthlessness
- Hopelessness or pessimism about the future
- Thoughts of death, suicidal ideation, self-harm thoughts/acts
- Sleep disturbance (insomnia or hypersomnia)
- Appetite and weight change outside expected developmental pattern
- Low energy, fatigue, reduced activity
- Psychomotor agitation or slowing
- Somatic complaints, especially in younger children (headache, abdominal pain, musculoskeletal pains)
- Excessive crying, clinginess, or separation anxiety in younger children
Signs
- Flat, restricted, or irritable affect on mental state examination
- Psychomotor retardation or agitation
- Reduced eye contact, slowed speech, reduced spontaneity
- Self-neglect or decline in personal care
- Evidence of self-harm (e. g, superficial cuts, burns, ligature marks)
- Functional decline at school/home despite effort to compensate
- Possible weight change and sleep-related daytime tiredness
- Signs suggesting abuse/neglect or safeguarding concerns
Investigations
Management
Lifestyle Modifications
- Build a collaborative, age-appropriate care plan with the young person and family; address confidentiality, consent (Gillick competence/Fraser), and safeguarding
- Psychoeducation on depression course, relapse risk, treatment expectations, and early warning signs
- Structured routine: regular sleep-wake schedule, daytime activity, graded return to school/college, and reduction of social withdrawal
- Physical activity and behavioural activation (small, scheduled rewarding activities)
- Family-focused support: improve communication, reduce conflict, and involve school pastoral/SEN teams
- Address psychosocial stressors (bullying, discrimination, housing/financial stress, trauma support pathways)
- Crisis/safety plan including emergency contacts and clear escalation for suicidality
Pharmacological Treatment
Selective serotonin reuptake inhibitor (first-line when medication is indicated, usually with psychological therapy and specialist CAMHS input)
- Fluoxetine oral: start 10 mg once daily, increase to 20 mg once daily after 1 week if needed/tolerated (BNF for children)
Fluoxetine is the preferred SSRI in under-18s. Monitor closely in first weeks for agitation, mood switching, and emergent suicidal thinking; review frequently after initiation and dose changes.
Alternative SSRI (specialist second-line/off-label in many under-18 settings)
- Sertraline oral (off-label for depression in under-18s): often 25-50 mg once daily initially, titrated gradually (e. g, by 25-50 mg) to usual adolescent range up to 200 mg/day under specialist supervision
- Citalopram oral (off-label for depression in under-18s): commonly 10 mg once daily initially, cautious titration if needed; avoid high doses due to QT risk
Use only with specialist advice when inadequate response/intolerance to fluoxetine. Check interactions and ECG risk factors, particularly with citalopram.
Complications
- Suicide (most serious complication)
- Suicide attempts and recurrent self-harm
- Recurrent depressive episodes/relapse
- Persistence of depression into adulthood with chronic functional impairment
- Poor educational attainment and school non-attendance
- Comorbid anxiety, substance misuse, and other psychiatric disorders
- Social and occupational disadvantage in later life, including relationship and financial difficulties
- Increased risk-taking outcomes (e. g, criminal convictions, teenage pregnancy in cohort data)
- Small but important treatment-emergent suicidality risk with SSRIs
Prognosis
Prognosis is guarded without effective treatment: only a minority recover rapidly (about 10% by 3 months), around half remain depressed at 12 months, and a substantial proportion remain symptomatic at 24 months. Non-response to first treatment is common, and relapse is frequent (roughly 40% within 2 years; up to 70% within 5 years), with many patients experiencing recurrent episodes in adult life.
Sources & References
🏥BMJ Best Practice(6)
✅NICE Guidelines(1)
- Depression in children[overview]
📖Textbook References(12)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 396)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1147)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1054)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1416)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 146)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 145)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 934)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 934)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 345, 346)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 356, 357)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 304, 305)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1113)[context]