Should I Start Psychiatric Medication for My Pediatric Patient with Depression?

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We are frequently asked when medication should be started after a pediatric patient presents with depression. The answer to this question depends on several considerations and will vary depending on each patient’s individual circumstances. However, the clinician can ask themselves the following questions to help guide the decision-making process.  

• Do we have the right diagnosis?
  Before we start a psychiatric medication, we want to make sure a thorough assessment has been conducted and that the patient meets diagnostic criteria for a particular diagnosis. This includes asking if the diagnosis is causing functional impairment and if the diagnosis could be better explained by another diagnosis. It is helpful to understand a patient’s baseline and how the symptoms of depression are causing changes from this — are they struggling more with school, are they no longer enjoying activities they previously loved, are they isolating from friends and family, or having significant disturbances in sleep or appetite? Screening tools like the PHQ-9 may help to gather initial data about symptoms of the diagnosis and help track symptoms over time, although they are not diagnostic alone. We also want to consider common psychiatric disorders that have overlapping symptoms with depression and could better explain the symptoms or be co-morbid with the depression including anxiety, ADHD, substance use disorders, or post-traumatic stress disorder which may alter our treatment recommendations.  
   
• How severe are the symptoms?
  Psychiatric medications are recommended for pediatric depression when depression is in the moderate to severe symptom range. Considering again how significant the functional impairment is will help illustrate the severity of the disorder. Another consideration of severity is assessing safety concerns and doing a thorough safety evaluation to determine if symptoms related to suicidal ideation are present.  
   
• Has psychotherapy been considered and tried?
  Psychotherapy is the first line treatment for pediatric depression at all levels of severity. We have evidence that combining psychotherapy with medication for moderate to severe depression will lead to faster recovery, but with milder levels of symptom severity, psychotherapy should be tried first. If a patient is having difficulty engaging in psychotherapy due to the severity of depressive symptoms (low motivation, energy, and focus to name a few), the combination of medication and therapy would be a good next step.  
   
• Do the patient and family want to try medication?
  Starting psychiatric medication should be a collaborative decision. Families should be informed of risks, benefits, and alternatives and provide informed consent prior to starting psychiatric medication for depression.  

Deciding when to start medication for pediatric depression can be complex, but asking yourself these questions can help guide your decision making.  

Please reach out to APAL at 888-290-1336 to discuss your specific case for additional support in making these recommendations for your patients.