Becoming comfortable with diagnosing depression in pediatrics

In the October 2019 issue of Contemporary Pediatrics, Dr. Michael Shapiro looks at depression in preschool aged kids. For many of us in pediatrics, depression and other related diagnoses can present a challenge. Our counterparts who treat adults see and treat depression more often and are often more comfortable with both diagnosis and treatment. I think this is partially because of something that Dr. Shapiro mentions in the article’s opening, we think of childhood as carefree and happy. Unfortunately, this is not always the case. 

Depression in this age group is a challenging diagnosis to make and often is a diagnosis of exclusion. From my personal experience and what the article mentions, stomach pains and headaches seem to be the most common physical symptoms that children with underlying depression display. These often lead to many office visits and missed preschool or daycare. It is interesting that not eating well is more common in this age group whereas overeating is more prevalent in older children and adults. I also found it very interesting that genetics do not play a bigger role in the younger patients as it seems to in the older children and adults. Age appropriate screening tools should help us with identifying these patients more efficiently. 

Anxiety and depression in this age group share many of the same signs and symptoms and separating 1 diagnosis from the other may be a hard task. Dr. Shapiro suggests that we do not need to know if it is 1 diagnosis or the other and instead concentrate on finding the underlying cause. I think most pediatric providers are watchful for external causes such as abuse, neglect, or other situations that may induce depression and or anxiety in this age. These causes seem to be identified more consistently and treated quicker.

I found it interesting that both the risk of suicide and the genetic expression of depression seem to increase around the age of puberty. Children that come from parents who both have a history of depression risk seem to see the chance go up greatly when they were aged around 12 to 13 years. This is also the timeframe where the risk of suicide increases. In our practice over the past few years, we have seen a significant increase in younger and younger children being referred to us to clear to return to school after making either suicidal or homicidal statements in school. Although I do not think that many of us feel truly comfortable clearing children’s return to school, it is good to know that there is a reduced risk in the younger population. Weeding through which patients can be cleared to return to school and which ones need to be further evaluated by a mental health provider has proven to increase anxiety in providers at my practice and also in myself. 

The author points out that the earlier onset of depression predicts an increase in episodes of depression later in life. I know that in many areas of the United States there is a shortage of mental health providers which makes referrals harder at times. Emergency departments (EDs) are seeing a large increase of children that need inpatient admissions, but an overall shortage of inpatient beds. I have heard of EDs having to board pediatric patients for up to 30 days in the ED before an inpatient bed becomes available. This burden spreads back out to the primary providers to help bridge the gap. In the past few years most of us have started prescribing antidepressant medications more and more. A great chart is included in the article that shows the US Food and Drug Administration-approved range for the most common medications. In the preschool age range, there are very few choices. I agree with the author that starting medications in this range may best be left to psychiatry providers. Referrals to psychology for treatment is probably appropriate in most if not all situations. 

Mr. Smith, Member-at-Large and Board Member for SPAP, received his Bachelor of Science in Biology from Georgia Southwestern College in Americus, Georgia, next attending the University of Georgia for master’s work in education and later Emory University Physician Assistant school from which he obtained his Master of Medical Science.

In addition to membership in SPAP, Mr. Smith is also a member of the Georgia Association of Physician Assistants, American Academy of Physician Assistants, and the American Academy of Pediatrics. He is credentialed at Piedmont Columbus Regional Hospital where he chairs the Pediatric Preparedness Committee. He also is a Co-Trainer for the Pediatric Readiness Quality Collaborative, a national program through the Emergency Medical Services for Children.

In December of 2014, Mr. Smith earned a Certificate of Added Qualifications in Pediatrics from the National Commission on Certifications of Physician Assistants (NCCPA). This certification is in addition to his certification from the NCCPA and demonstrates knowledge and skills specific to pediatrics. He is married to Renee Smith, also a Physician Assistant, and they have one child, Emma.

Seeing the chief complaint of depression or anxiety can induce the same reaction in providers, but this article gives some great insight into identifying and treating these patients. Using the mentioned screening tools and an understanding of the risk factors should help us diagnose and treat this population better and hopefully reduce anxiety and depression in the provider as well.