Evidence-based assessment/Depression in youth (assessment portfolio)/extended version

What is a "portfolio"?

 * For background information on what assessment portfolios are, click the link in the heading above.
 * Does all this feel like TMI? Click here to go to a condensed version.

Diagnostic criteria for depression in youth
ICD-11 Diagnostic Criteria
 * Depressive Disorders
 * Depressive disorders are characterized by depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioural, or neurovegetative symptoms that significantly affect the individual’s ability to function. A depressive disorder should not be diagnosed in individuals who have ever experienced a manic, mixed or hypomanic episode, which would indicate the presence of a bipolar disorder.
 * Single Episode Depressive Disorder
 * Single episode depressive disorder is characterized by the presence or history of one depressive episode when there is no history of prior depressive episodes. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.
 * Note: The ICD-11 lists 10 additional subcategories of single episode depressive disorder. They can be found here.
 * Recurrent Depressive Disorder
 * Recurrent depressive disorder is characterized by a history or at least two depressive episodes separated by at least several months without significant mood disturbance. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a Bipolar disorder.
 * Note: The ICD-11 lists 10 additional subcategories of recurrent depressive disorder. They can be found here.
 * Dysthymic Disorder
 * Dysthymic disorder is characterized by a persistent depressive mood (i.e., lasting 2 years or more), for most of the day, for more days than not. In children and adolescents depressed mood can manifest as pervasive irritability.The depressed mood is accompanied by additional symptoms such as markedly diminished interest or pleasure in activities, reduced concentration and attention or indecisiveness, low self-worth or excessive or inappropriate guilt, hopelessness about the future, disturbed sleep or increased sleep, diminished or increased appetite, or low energy or fatigue. During the first 2 years of the disorder, there has never been a 2-week period during which the number and duration of symptoms were sufficient to meet the diagnostic requirements for a Depressive Episode. There is no history of Manic, Mixed, or Hypomanic Episodes.
 * Mixed Depressive and Anxiety Disorder
 * Mixed depressive and anxiety disorder is characterized by symptoms of both anxiety and depression more days than not for a period of two weeks or more. Neither set of symptoms, considered separately, is sufficiently severe, numerous, or persistent to justify a diagnosis of a depressive episode, dysthymia or an anxiety and fear-related disorder. Depressed mood or diminished interest in activities must be present accompanied by additional depressive symptoms as well as multiple symptoms of anxiety. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.

Changes in DSM-5

 * The diagnostic criteria for depressive disorders changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

Base rates of adolescent depression in different clinical settings
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rates of adolescent depression that they are likely to see in their clinical practices.


 * To find prevalence rates across multiple disorders, click here.

p:Parent interviewed as component of diagnostic assessment; y:youth interviewed as part of diagnostic assessment.

Psychometric properties of screening instruments for adolescent depression
The following section contains a list of screening and diagnostic instruments for adolescent depression. The section includes administration information, psychometric data, and PDFs or links to the screenings.
 * Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
 * For a list of more broadly-reaching screening instruments, click here.

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Interpreting depression screening measure scores
For information on interpreting screening measure scores, click here.

Gold standard diagnostic interviews

 * For a list of broad-reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Severity scales for adolescent depression
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase
The following section contains a brief overview of treatment options for depression and a list of process and outcome measures for adolescent depression. The section includes benchmarks based on published norms and on mood samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information on differences between process and outcome measures, see the page on the process phase of assessment.

Process measures
A. Mood and Energy Thermometer This is an improved and practical way of monitoring complex mood cycles and daily schedules. Given that some clinicians and patients may get confused about different 1 to 10 scales (e.g., a 10 could mean extreme depression or extreme mania or no depression), the Mood & Energy Thermometer improves the language in communicating (and monitoring) mood. Moreover, many children report their energy levels more accurately than their moods and therefore, energy levels are incorporated into the mood rating. The Mood & Energy Thermometer that was developed at Western Psychiatric Institute and Clinic (WPIC; and used in about 400 kids) rates mania and increased energy on a 1 to 10 scale, rates depression and tiredness on a -1 to -10 scale, and attempts to form a common language between patients, families, and clinicians. This scale also takes into account the amount of time spent depressed or manic; for example, -4 would mean “mild depression” and “mild tiredness” present ≥50% of the time, and -3 would mean “mild depression” and “mild tiredness” present < 50% of the time. The inclusion of measuring energy levels is consistent with the DSM-5, as energy level is now included in the DSM-5 as a main mood symptom criterion. Bipolar track patients (whether they experienced mania, depression, or mixed features) rated their (Q: is the parent rating his/her own moods/energy, or his/her child's?) mood and energy levels every day on this scale, and a master’s-level clinician met with them on a daily basis to help them better identify and record their mood symptoms, which has significant clinical value not only for treatment but also to prevent future episodes.


 * Mood and Energy Thermometer


 * Mood and Energy Thermometer with Anger and Anxiety (with recording/monitoring card)

B. Life Charts
 * Mood and Energy Thermometer with Anger and Anxiety - Simplified Version
 * To learn more about how life charts can be used with adolescent depression, see here
 * Life Charts for Depression and Bipolar

Outcome and severity measures

 * This table includes clinically significant benchmarks for Depression in Youth specific outcome measures
 * Information on how to interpret this table can be found here.
 * Additionally, these vignettes might be helpful resources for understanding appropriate adaptations of outcome measures in practice.
 *  For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks,  see here.

4.1.b – Beck Depression Inventory- II, ages 13 and up

4.1.c – KSADS Depression Rating Scale (Axelson, 2006)

4.1.d – Children’s Depression Rating Scale-Revised (CDRS-R; Elva et al., 1996)

4.1.e – Children’s Depression Inventory, ages 7-17 (CDI; Kovacs, 1992)

Treatment
For treatment of depression in youth, there are two main types of treatment: psychosocial interventions and medication. There has been significant controversy over the use of psychotropic medications with children and many studies have looked at the efficacy of medication, psychosocial interventions, or a combination of both.

One of the most effective treatments for depression in youth is psychosocial interventions, which has been shown to lead to substantial reduction in symptoms for children and adolescents. A recent meta-analysis found that psychosocial interventions had an effect size of 1.14 and the reduction in depressive symptoms was maintained over time. On the other hand, the meta-analysis reported that pharmacological treatments did not lead to significant symptom reduction and had an effect size of 0.19. Additionally, medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) have presented concerns about increasing suicidality and harmful behavior. One of the most commonly used psychosocial interventions is cognitive behavioral therapy, which consists of individual or group sessions in which the provider helps the client address cognitive distortions and maladaptive thinking patterns that contribute to the maintenance of depressive thoughts.


 * Please refer to the page on adolescent depression for more information on available treatment for adolescent depression or go to Effective Child Therapy for a curated resource on effective treatments for adolescent depression.

External Resources

 * 1) ICD-10 diagnostic criteria
 * 2) Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
 * 3) NIMH (information about adolescent depression)
 * 4) John's Hopkins Resource Guide (a guide about adolescent depression, treatment, and more)
 * 5) OMIM (Online Mendelian Inheritance in Man)
 * 6) 608516
 * 7) 608520
 * 8) 608691
 * 9) eMedicine entry for adult depression
 * 10) Effective Child Therapy
 * 11) Effective Child Therapy is a website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.