Physically ill pediatric patients must meet the full DSM-IV-TR criteria for primary depressive episode for this diagnosis to be made; however, no standardized approach currently exists for diagnosing depression among individuals who are physically ill. Clinicians are challenged to determine whether the classic signs and symptoms of clinical depression, such as dysphoria, anhedonia, fatigue, pain, psycho-motor retardation, anorexia, weight loss, cognitive impairment, and insomnia, represent demoralization, the physical illness itself, the effects of medical treatments, and/or prolonged separations from family and friends. The presence of feelings of worth-lessness, inappropriate guilt, diminished ability to think, or suicidal thoughts is generally more consistent with the diagnosis of a primary depressive episode (Goldston et al. 1994). Youngsters at risk for a primary depression are those who have had a previous depressive episode, histories of parental depression, adverse family environments, a family history of mood disorders, and the experiences of early life trauma (Evans et al. 2005b). Although thoughts of death or a hastened desire for death is not a reliable sign for depressive disorders in this population and may instead represent demoralization (Kissane et al. 2001; Radloff 1977), a careful assessment remains essential. Youngsters with a primary depressive disorder who are at increased risk for suicide are those who have a history of prior suicide attempts, current suicidal ideation, intent and plan, psychiatric comorbidity, hopelessness, poor social and family supports, histories of childhood sexual abuse, and impulsivity (Evans et al. 2005b).
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