CCPR: Can you start by describing the general nature of depression in children and teens?
Dr. Feder: Think of depression as a trait cutting across diagnostic boundaries of all child and adult psychiatric conditions. This depression component is driven by stress, trouble experiencing rewards, and disruption of the natural drive to connect with others (Luyten P and Fonagy P, Clin Psychol Rev 2018;64:87–98). This results in anything from subtle negativity to profound hopelessness. In severe cases, there may be suicidal thoughts. Younger children have concrete ideas such as “the world is bad, I’m bad, and the future is bad” and have academic and social problems. These same ideas typically underlie depression in older patients but are cloaked in more complex ideas. Teens can lose their veneer of indestructibility. Young adults may despair they will never find love or a meaningful career.

CCPR: What kinds of depression occur in children and teens?
Dr. Feder: The DSM-5-TR includes several depressive disorders, all requiring different approaches for care. Depression conditions include major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder. There are also adjustment disorders, gender dysphoria, trauma-related disorders, grief, and prolonged grief disorder. Depression in any form is pervasive and toxic, creating social, cognitive, and motor dysfunction. Depression interferes with child and teen development, partly by reducing their natural drive to explore and achieve (Luyten and Fonagy, 2018). But there’s more to it, since most kids come to us with multiple conditions, not one discrete disorder.

CCPR: How do depressive symptoms show up in other conditions?
Dr. Feder: Depressive symptoms can co-occur across all mental health problems in children and teens. In ADHD, children are often told “no,” eroding their self-esteem and triggering depressive symptoms (Editor’s note: See CCPR July/August/September 2025 for more). In autism, if a teen can’t fit into peer groups, they can become depressed. Other forms of depression in childhood relate to lack of a sense of competence, such as in learning disorders like dyscalculia, dysgraphia, or dyslexia. These conditions make children and teens feel like they’re not as good as their peers at school. Depression makes other problems more likely to manifest, such as anxiety and substance use disorders, and—perhaps most importantly—depression drives suicidal behavior.

CCPR: How does the presentation of depression differ between children and teens?
Dr. Feder: Depression in young children might present as poor eating or delayed development. Depressed school-aged children might be withdrawn or irritable and not doing their work or socializing. Depressed teens might be self-medicating, engaging in self-harm, or not planning for their future (Mullen S, Ment Health Clin 2018;8(6):275–283).

CCPR: How do you assess children and teens to identify and differentiate between depressive disorders?
Dr. Feder: I start by looking for usual characteristics of depression beyond depressed mood, using the mnemonic SIG E CAPS: Sleep disturbance, loss of Interest in usual activities, Guilt or ruminations, reduced Energy, poor Concentration, change in Appetite, Psychomotor changes, and Suicidal thinking or actions. These symptoms help determine whether you’re identifying a depressive disorder. Next, I take a thorough history from the child, caregivers, and collateral sources (eg, teachers) to understand the child’s family history, developmental history, and health history—including physical health and social and community circumstances. Be sure to conduct a safety check to identify potential dangers such as firearms, ropes and cords, medications, and other toxins. For teens, I also assess driving safety. My observation of the child or teen is important; however, a depressed child or teen may seem OK. For example, they may get adequate exercise or interact well with peers. So while a patient who looks depressed in all settings gives consistency to the picture, lack of consistency is not reason to rule out depression.

CCPR: What specific elements in the medical history and neuropsychiatric review are important for depression?
Dr. Feder: Since depression can be linked to essentially every condition, every part of the patient’s history might hold an important clue: Infectious illnesses, pubertal changes, sensorimotor function, learning styles, or sexuality may all be impacting mental health. Trauma and maltreatment are important to cover, as well as exposure to social media and community distress. In urgent situations, I screen these areas rapidly but still do a thorough safety check and make a plan to develop the information more fully over the course of my follow-up.

CCPR: What does this history tell you? 
Dr. Feder: Everyone I work with has a unique set of biopsychosocial factors. Once I identify these factors, I can see how—for example—ADHD, a single-parent household, and anemia from heavy menses each contribute to difficulty coping and lead to a particular kind of depression, whether acute or persistent.

CCPR: How do you use this biopsychosocial list of factors to individualize treatment of depression?
Dr. Feder: I address co-occurring conditions while treating depression—for instance, educational intervention for learning disorders, developmental relationship–based care for autism, and usually stimulant medications for ADHD. I usually flip the biopsychosocial model backwards, prioritizing the social piece first. If a child is in the wrong school placement or being bullied online, therapy and medication are unlikely to overcome that. I look next at psychological factors since good therapy (cognitive behavioral therapy [CBT], interpersonal psychotherapy, and others) can help kids manage their thoughts and emotions and support child-caregiver relationships. Then I might go to medications to see if they help. That said, if there is an obvious place to intervene sooner, like treating anemia medically or treating obsessive-compulsive disorder with response prevention, I’ll pursue those up front.

“I usually flip the biopsychosocial model backwards, prioritizing the social piece first. If a child is in the wrong school placement or being bullied online, therapy and medication are unlikely to overcome that.”

Joshua Feder, MD 

CCPR: Can you give us a specific case example? 
Dr. Feder: I had an autistic middle schooler who was acutely depressed with suicidal thinking; he had a chronic sadness consistent with persistent depressive disorder. Medications and therapy were of limited benefit. Once I got the full story from family and teachers, I learned that he was lonely and very sensitive to the heat in his classroom. I lobbied for air conditioning, which didn’t pan out, but we got a fan in there and it worked well. He returned to more of a baseline sadness during periods of increased ambient heat. Then we worked on facilitating social activity, in his case through sports. Over time the sadness lifted too. Medications and therapy were of great help, but they weren’t enough.

CCPR: How do social determinants of health impact depression presentation and treatment?
Dr. Feder: They have a significant impact. Displacement—whether leaving your home country, another part of the US, or a neighborhood due to domestic violence—affects depression because you lose supports, extended family, friends, or economic security. When people are poor, they might have food insecurity and worry about eating, or they might worry about having a place to live if they are unhoused or at risk. They may come for treatment saying they’re depressed, but if you don’t know these circumstances and help address concerns, it’s hard to treat the depressive ­condition. Learn the family culture. If you presume the goal is teenage independence and separation-individuation, but the family culture values staying close and helping each other, you’re missing the mark. If you interpret a teen wanting to stay in town for college as depression rather than a cultural value, you might have it wrong.

CCPR: Are there common treatment elements for depression despite different underlying causes?
Dr. Feder: Yes. Mediterranean diets can help depression in children despite etiology (Editor’s note: See CCPR July/August/September 2025). Exercise also helps, and better sleep reduces suicidality (Bevan E et al, Clin J Sport Med 2025;35(2):206–223; Fernandez SN et al, Child Adolesc Psychiatr Clin N Am 2021;30(1):269–282). For therapy, CBT helps children identify how negative thoughts, emotions, and behaviors are linked and how to change them. I favor parent-mediated, developmental relationship–based approaches—helping parents find ways to help their child be calm and connected in mutually meaningful problem-solving interactions. The child then learns to calm themselves and problem-solve independently over time. Parents feel empowered, and kids do too. Therapy can work even with reluctant minors, and medication, while less robust than placebo in many studies, can be lifesaving. Side effects like behavioral activation with selective serotonin reuptake inhibitors (SSRIs) are common, and new suicidality can occur with a relative risk of about 1.28 (Li K et al, Front Psychiatry 2022;13:880496).

CCPR: How do you decide what level of care to recommend?
Dr. Feder: Outpatient care, where you may only see a patient once every few weeks, can be sufficient for patients who are depressed but functioning adequately at home and school. Consider intensive outpatient treatment for those patients whose function is slipping more—this typically involves after-school sessions for a couple of hours, several times weekly. Consider partial hospitalization for those not functioning in school or home environments but not needing 24/7 safety monitoring. This entails four or five days a week learning skills and receiving closer observation, possibly with more assertive medication approaches. Inpatient acute care is for those at relatively acute risk for self-harm, typically with suicidal thoughts they may act on. When you’re thinking about level of care in extreme and chronic situations, residential care becomes an option.

CCPR: What’s your approach to medication management in pediatric depression?
Dr. Feder: I target medication to ancillary symptoms first—for instance, stimulant medication for ADHD or melatonin, valerian, or chamomile for sleep. I typically start antidepressants when there are significant depression symptoms, environmental changes are in place, and therapy isn’t working fast enough. I usually try fluoxetine first, then sertraline, and maybe citalopram next. I avoid serotonin/norepinephrine reuptake inhibitors because the data aren’t there, though there’s some evidence for duloxetine if someone isn’t tolerating SSRIs well. I watch for activation with SSRIs and for sedation or gastrointestinal symptoms with duloxetine. If things worsen, I consider adjunctive medications—adding a stimulant, thyroxine in some cases, or lithium, which is also antisuicidal. I might try valproate, but not in people who might become pregnant, as it can cause polycystic ovary syndrome. Second-generation antipsychotics like aripiprazole are a last resort, and I prefer ones that are less metabolically problematic, like ziprasidone or lurasidone. We’re working off-label in almost every case except for SSRIs (Feder J et al. Child Medication Fact Book for Psychiatric Practice. 2nd ed. Newburyport, MA: Carlat Publishing; 2023).

CCPR: What can you do to address depression following natural disasters and community trauma?
Dr. Feder: In natural and man-made disasters, there’s a threat to you and everyone around you, plus some people are impacted while others aren’t. Kids may be separated from their community, away from friends, and losing usual enjoyable activities—all significantly impacting mood. Families that maintain routines for sleeping, eating, and studying while carefully navigating dangers do better, whether at home, in shelters, or displaced elsewhere. Trauma-informed care is important. Be safe and trustworthy—don’t lie to kids you work with. If someone died, use the word “died” without gory details but without being opaque. Give kids choices in decisions and work together on care plans. For instance, “We can try therapy, medication, or both, and I think getting you reconnected to friends will help—tell me what you think we should try first” (Editor’s note: For more, see CCPR July/August/September 2020).

CCPR: How do you explain different types of depression to families to gain treatment support?
Dr. Feder: I tell families: “The famous first line of Leo Tolstoy’s novel Anna Karenina is, ‘All happy families are alike; each unhappy family is unhappy in its own way.’ Everybody’s depression is also different, and our job is to figure out what it’s like for your kid. There are many reasons for depression, usually more than one. But if we take our time and figure it out, we will find ways to help them feel better.”

CCPR: How do you navigate continuing care for a depressed child or teen?
Dr. Feder: Track restoration of functioning and developmental progress. See if the child or teen is 1) regulated enough to interact (not too withdrawn, not too agitated); 2) able to connect to important people around them; and 3) able to engage in meaningful interactions that help solve problems collaboratively while building independent problem-solving abilities. This impacts their willingness to achieve and compete rather than being held back by depression. Patients and parents will keep telling you what’s wrong, so continued assessment helps refine your understanding and address foundational issues causing depression rather than treating symptoms. Complex problems like depression require complex individualized approaches, but sometimes one intervention, like addressing a learning disability, makes a big difference. Remember that medication won’t fix a bad school placement—environmental factors must be addressed first for treatment to be effective.

CCPR: Thank you for your time, Dr. Feder.