Depression

If any of the below occur and you see these in your child (or in yourself, a spouse, or another relative), get professional help fast. Your pediatrician or family doctor can guide you.

• Inability to concentrate.
• Difficulty sleeping or sleeping excessively.
•   Loss of energy or interest.
•   Falling grades.
• They don’t want to do formerly fun things because nothing makes them feel happy.
• They ma write poetry about death or draw unhappy themes even of death in their art.
•   If they have been bullied or put down they may be particularly vulnerable.
•   If there has been a break up with a close friend or a romantic relationship.
•   Watch for depression or suicicde talk or writing.
•   If there is a family history of depression or bipolar disorder and they show changes in sleep patterns or moods or any of the above they will need help fast.

If they are being treated for the depression and not doing well they need further evaluation.

Despair

Before someone attempts suicide they fall into despair. Adults may be in despair for several days, weeks, even months. Teenagers get into despair very quickly in a matter of minutes when something bad happens. Suicide is a result of despair.

People feel so out of harmony with everything they know, which is a horrible feeling that death appears to be the only relief. It is a comforting idea, something that will give them a sense of harmony with ceasing to exist. However the problem is that despair contains a false belief that fools you that there is nothing more you can do to feel better. That is not true. The real truth about despair is that you can do something more to make life work, to go on living. It may be painful for you to move forward but despair simply means you are out of your ability to handle life with what you currently know in your life. Therefore you must create something more that works. Once you do the despair and the suicide urge goes away.

It is important to know this if you are a caregiver or someone around you appears to be getting into despair — a very dangerous condition which often leads to suicide or suicide attempts. Get help quickly for someone in this situation. If you feel despair yourself, fight off the false belief or despair that you can’t do anything to help. Instead realize you can do something. Take the risk even though you feel very uncertain to try something new. When you do the despair will go away.

If your children appear to be in despair and believe that there’s nothing more they can do tell help them find ways to make changes in their thinking and their lives. Let them know they need to do something that will work. Death is not the option. It is too permanent.

Most who despair are glad to be alive, soon after.

Most women with real postpartum depression are never diagnosed. Even though postpartum depression is very common, and even though identifying it can help both the baby and the mother, most cases slip through the cracks. A simple new 3-question test has proven very reliable at detecting postpartum depression. Perhaps surprisingly, none of the questions were about feeling sad, feeling happy, laughing, crying, feeling hopeful or hopeless, or being able to sleep. Nevertheless, the brief 3-question test was able to identify accurately 95 percent of the depressed women in a September 2008 study. It was about as reliable as more involved questionnaires, and much more practical because of its brevity.

The likelihood of postpartum depression usually peaks when the baby is about 12 weeks old, give or take a couple of weeks. I understand that pediatric offices are very busy these days, but I would love to see this 3-question test (or a more extensive one) for moms at every well-baby visit in the first 6-months. Too many moms and babies go through this without the support they deserve.

What are the 3 questions? They focus on a unique and important part of postpartum depression: excess anxiety. Some anxiety for new parents, of course, goes with the territory. Parenthood is, after all, a new adventure into the unknown. You love a new person so much, it’s normal to feel fear and anxiety. But when anxiety or fear predominate your daily experience with a new baby, it can be a sign of postpartum depression.

Here is the test:

As you have recently had a baby, we would like to know how you are feeling. Please underline the answer that comes closest to what you have felt IN THE PAST 7 DAYS, not just how you feel today.

1.  I have blamed myself unnecessarily when things went wrong.
a. Yes, most of the time 3
b. Yes, some of the time 2
c. Not very often 1
d. No, never 0

2. I have been anxious or worried for no good reason.
a. No, not at all 0
b. Hardly ever 1
c. Yes, sometimes 2
d. Yes, very often 3

3. I have felt scared or panicky for no very good reason.
a. Yes, quite a lot 3
b. Yes, sometimes 2
c. No, not much 1
d. No, not at all 0

The way I have presented it here, the maximum possible score is 9. Women with a score of 3 or more may or may not be depressed, but deserve further evaluation to be sure. If a cutoff score of 4 or even higher were used, the results would more likely indicate depression, but some depressed women would be missed. The purpose of a screening test is to find those who would benefit from more evaluation. This test has only been validated as a screening tool for moms. Depressed dads are also important to identify, but they may have very different symptoms.

Kabir K, Sheeder J, and Kelly LS. Identifying Postpartum Depression: Are 3 Questions as Good as 10? Pediatrics Sep 2008; 112:e696-702.

*Doctors will usually take the total score and multiply it by 10/3.  This way 30 is the maximum possible score, and those with a score of 10 or more should be evaluated.  This keeps the score consistent with other postpartum depression test currently in use.

You may feel a rainbow of emotions during the days following your baby’s birth, sometimes in bewildering succession, sometimes several conflicting emotions at the same time.

As magical as the journey of parenthood is, it often begins with a period of feeling blue. Women’s bodies are the scene of a powerful changing tide of hormones in the days and weeks after a baby is born. The rising hormone levels that gradually produced the incredible changes in your body during the time you were carrying your baby have now precipitously dropped.

Most new mothers (perhaps as many as ninety percent) will have periods of weepiness, mood swings, anxiety, unhappiness, and regret. Usually this lasts for a few days or less and is quickly forgotten. It’s not unusual, however, for the blue period to come and go for six weeks. For some moms, the blues don’t begin until the baby stops nursing (another time of major hormonal shifts). Hormones, however, are not the entire story… Join Dr. Greene on Wednesday for more on Postpartum Blues.

This is an excerpt from: From First Kicks to First Steps: Nurturing Your Babys Development from Pregnancy Through the First Year of Life, McGraw-Hill, 2004, Pp. 198-202

Dads matter. When people think about depression soon after a baby is born, they often forget about fathers. But many new dads do get depressed, and you can read their depression in their children’s behavior! Fathers and their well-being have an important effect on their babies’ development, but this has been too little studied.

The first large study, of over 8000 fathers and their babies in Finland, was reported in the June 25 – July 1 2005 Lancet. When the babies were 8 weeks old, about 4 percent of the fathers were depressed. This is consistent with the meager results from previous small studies around the world that report between 1 and 26 percent of new fathers become depressed. But the Lancet study looked beyond the first weeks of life and looked at the children when they were 3 ½ years old. Even after taking into account other factors (such as depression in the mother, or the family’s education and socio-economic status), father’s depression when the baby was 8 weeks old had an independent and significant impact on the child.

Conduct problems, hyperactivity, and total problems in the child were each more likely if Dad had been depressed. Dads matter. As I often remind mothers, if the ride is turbulent, and the oxygen masks should fall from the ceiling of the plane, first put on your own mask, so that you will be able to help your children. If it feels like the sky is falling, do the same thing – taking care of yourself is often the first step to being better able to love your baby. (This is also a good principle to follow if you are having the best time of your life.) Don’t hesitate to get medical help if you suspect depression in either parent. Either way, take time to take care of yourselves.

In the turbulent weeks after a baby is born, simple things often fall by the wayside. Strategize together to get the best sleep, delicious healthy food, and active exercise – for both parents. Staying connected as a couple is also very important. All too often, little things might make a father feel incompetent or like an outsider. Both parents need to feel supported, welcomed, and encouraged by the other – for themselves, and in relation to the new baby. Families matter.

For most people who develop mental illnesses, the problem usually starts in childhood or adolescence, according to a study published in the June 6, 2005 Archives of General Psychiatry. Researchers from Harvard Medical School conducted face-to-face surveys of almost 10,000 adults to learn about how common psychological problems are in the general population, and at what ages they begin.

The most common specific problem in adults was major depression, followed by alcohol abuse, specific phobias, and social phobias. The most common broad class of disorders was anxiety disorders, followed by impulse-control disorders, mood disorders, and substance abuse disorders.

Across the board, half of all disorders in adults had started by age 14! This is astounding. The average age for the start of anxiety disorders and impulse-control disorders was even younger, at age 11. The starting ages were concentrated in a surprisingly narrow range for most of the disorders studied. For instance, half of all impulse-control disorders started between age 7 and 15.

Most of the illnesses were minor at the outset. Without help, mild or low-level problems can escalate later in life to severe or chronic depression, phobias, or anxieties. This calls for a change in our priorities and awareness. Most of our mental health budget is spent on adults. This striking study suggests that our efforts toward prevention, early detection, and early treatment should be focused on our youth.

A recent study has changed my thinking about ADHD, and I hope it changes the way that all children with ADHD are evaluated and treated. And that parents are treated. Parents deserve better understanding and support than they traditionally get. Dr. Andrea Chronis and her team at the University of Maryland make a compelling argument that whenever children have ADHD, getting help for their parents should be thoughtfully undertaken.

ADHD tends to run in families. In the Maryland ADHD Program study of 214 children, the parents of children with ADHD were 24 times more likely to have ADHD themselves than were parents of children without ADHD. These results were published in the December 2003 Journal of the American Academy of Child and Adolescent Psychiatry. As is often the case, many kids in the study also had Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) in addition to their ADHD. Their parents had higher rates of depression and other psychological problems, including alcohol and other types of substance abuse.

Is this genetic? Or might it result from the increased stress of dealing with ADHD? Both are probably true to some extent. Significantly, all treatments for ADHD tend to be less effective when the parents have their own psychological issues. It makes sense that parent with ADHD might be less able to make needed environmental changes. Even medications, however, are less effective when the parents. problems are untreated. This has important implications.

Whether or not parents have symptoms of their own, they are likely to be under great stress. Dealing with a child with ADHD can be exhausting, frustrating, and embarrassing (as well as creative, energizing, and delightful). Listening to parents and offering practical support should start at the beginning of an ADHD evaluation and continue through the course of treatment. The treatment plan should be developed with this in mind.

‘Medications alone are not sufficient to treat ADHD,’ Dr. Chronis emphasized when we spoke about her study. ‘We need to look beyond the child to recognize and treat the parents’ issues,’ for their own sakes and for the sakes of the children. Dr. Chronis is the director of the Maryland ADHD Program.

When treating obesity in children, I know that success is most likely if the whole family eats healthier and spends more time being active . even if only one child is obese. It makes deep sense to me that family changes would also have the greatest impact in ADHD, even if parents don.t have psychological issues. If parents do have ADHD or are depressed, it makes sense that success in the children would be extremely difficult without helping everyone.

I hope I never look at a child with ADHD in isolation again.

Antidepressant use in children has been coming under new scrutiny since Britain raised concerns about Paxil in June 2003. On October 27, 2003 the FDA issued a public health advisory to alert U.S. physicians about reports of increased suicidal thoughts and suicide attempts in children taking various antidepressant medications. They report that we don’t know enough yet to confirm or rule out increased danger from these drugs.

Further understanding is expected early in 2004. In the meantime, the FDA reports that they have evaluated the data on 7 antidepressants, and only found evidence that one (Prozac) is effective at reducing depression in children. Celexa, Effexor, Paxil, Remeron, Serzone, and Zoloft failed to show significant benefit for depressed kids in the 20 controlled studies evaluated by the FDA. Only Prozac has been approved by the FDA for use in kids.

If your child is already taking one of these medications, talk with your doctor before making any change. If you suspect your child may be depressed, talk with your doctor about the various treatment options available.

Depressed kids deserve help to get through their depression.

The popular antidepressant drug Effexor should not be started in children under the age of 18, according to a statement released September 19, 2003 by the British Committee on Safety of Medicines. They reported that recent tests in children showed no benefit from Effexor in treating childhood depression, but did show an increase in undesirable outcomes, including at least twice as many reports of hostility, suicidal thoughts, and episodes of self-harm in those taking the medicine compared to depressed children who were taking a placebo.

If your child is taking Effexor, do not stop the medicine abruptly; rather, discuss options with your child’s physician.

Effexor has been shown to be effective in adults, and to have fewer side effects in adults.

Childhood depression is different from adult depression; their developing brains are different from adult brains. They think differently than adults (even though both groups often lose sight of this).

I strongly support the Committee on Safety of Medicines’ efforts to evaluate the use of accepted medicines on children. Their disturbing conclusions are welcome. All too often, as illustrated by their June announcement warning against the use of Paxil in children, policies and practices have been developed largely based on studies done in adults.

Children deserve medicines known to be safe and effective for children.

About 69 percent of depressed children, aged 6 to 17, improved significantly while taking Zoloft for their depression, according to a study published in the August 27, 2003 JAMA, but data from the study suggests to me that another option may be an even better choice for some children. Zoloft is manufactured by Pfizer. I’m glad that Pfizer has funded a clinical trial on how the medication works in children. In this Pfizer-sponsored study, Zoloft was considered generally well tolerated. Each of the following side effects was seen in at least 5 percent of the children taking the medication, and at least twice as often as in the children in the study who only took placebo pills: insomnia, diarrhea, decreased appetite, vomiting, agitation, urinary incontinence, and purpura (bleeding into the skin or mucus membranes). Most of these side effects were considered mild or moderate by the researchers. Nine percent of those taking Zoloft in the study had to stop because of side effects. Children taking the medication tended to lose weight, while those taking placebo continued to grow during the study. The difference in weight change was about 1 pound per month between the two groups. There was no increase in suicidal behavior in those taking the Zoloft, unlike that found in some studies of children taking Paxilfor depression.

This study of Zoloft is important for two reasons. First, children do not respond to medicines the same way adults do. Even though children tend to have more side effects and less benefit than do adults with this medication, this study does demonstrate positive benefit in some children (again, unlike some studies of Paxil). There was a trend in the study suggesting that Zoloft becomes an even better choice at the upper end of the age range studied, with more benefit and fewer side effects.

But to me, what was most striking about the study was that fully 59 percent of depressed children taking the placebo pill had significant improvement in their depression and followed a very similar pattern of benefit to those taking the strong drug! At the beginning of the study, the children had an average CDSR-R depression score of about 64 points. Over the entire 10 weeks of the study, those taking the Zoloft had significant improvement – by an average of 22.84 points. Those taking the placebo also improved significantly, but clearly not quite as much – an average of 20.19 points. Depressed children deserve all the help they can get. It seems to me that identifying and addressing depression may be an even more important intervention than the modest extra benefit afforded by the prescription. Far too many depressed children suffer without this important help.

On June 10, 2003 the British government issued a very strong warning about the antidepressant Paxil, called Seroxat in Britain, saying that it “should not be used in children and adolescents under the age of 18 years to treat depressive illness.” The MHRA (the British equivalent of the U.S. FDA) evaluated 9 recent studies of its use in children and concluded that in children it has higher risk and less benefit than previously thought.

The risk is that it can make depressed children suicidal. Those depressed children on the medicine were 1.5 to 3.2 times more likely than those taking placebo to engage in self-harm or episodes of suicidal behavior.

Paxil also showed a striking lack of benefit in children, “These data do not demonstrate efficacy in depressive illness in this age group.” They warn that no child should be started on Paxil for depression, but if a child is already on it they recommend considering completing the planned treatment as a valid option. The FDA is conducting its own investigation into the matter, but has not reached conclusions yet. The manufacturer has been quoted as saying the British authorities overreacted.

Like so many commonly used medications, Paxil or Seroxat has never been approved for use by children in the U.S. or Britain. Nevertheless, doctors write many prescriptions for it. Why? Most of the medicines used to treat children have not been adequately tested in children. Most safety and benefit testing is done on adults. Children’s growing bodies do not respond the same way as adults’ – to medicines or to pesticides on food. However this Paxil issue plays out, is a vivid reminder that we must do better in ensuring that medicines and food that we give to our children have been carefully evaluated for children!