Depression in Children and Adolescents


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Highlights: Depression in Children and Adolescents

Depressive disorders, which include major depressive disorder (unipolar depression), dysthymic disorder (chronic, mild depression), and bipolar disorder (manic-depression), can have far-reaching effects on the functioning and adjustment of young people. Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat and enjoy once-pleasurable activities. Dysthymia involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives. Bipolar disorder is not nearly as prevalent as other forms of depressive disorders and is characterized by mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overly talkative and have a great deal of energy. Mania often affects thinking, judgment and social behavior in ways that cause serious problems and embarrassment.

Only in the past two decades has depression in children been taken seriously. The depressed child may pretend to be sick, refuse to go to school, cling to a parent or worry that the parent may die. Older children may sulk, get into trouble at school, be negative, be grouchy and feel misunderstood. Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary phase or is suffering from depression. Sometimes the parents become worried about how the child's behavior has changed, or a teacher mentions that "your child doesn't seem to be himself." In such a case, if a visit to the child's pediatrician rules out physical symptoms, the doctor will probably suggest that he be evaluated, preferably by a psychiatrist who specializes in the treatment of children. If treatment is needed, the doctor may suggest that another therapist, usually a social worker or a psychologist, provide therapy while the psychiatrist will oversee medication if it is needed. Parents should not be afraid to ask questions: What are the therapist's qualifications? What kind of therapy will the child have? Will the family as a whole participate in therapy? Will my child's therapy include an antidepressant? If so, what might the side effects be?

Symptoms

The diagnostic criteria and key defining features of major depressive disorder in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder may be more difficult in youth for several reasons. The way symptoms are expressed varies with the developmental stage of the child. In addition, children and young adolescents with depression may have difficulty in properly identifying and describing their internal emotional or mood states. For example, instead of communicating how bad they feel, they may act out and be irritable toward others, which may be interpreted simply as misbehavior or disobedience. Research has found that parents are even less likely to identify major depression in their adolescents than are the adolescents themselves.

Symptoms of Major Depressive Disorder Common to Adults, Children and Adolescents:

  • Persistent sad, anxious, or "empty" mood
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness or helplessness
  • Loss of interest or pleasure in hobbies and activities that were once enjoyable
  • Decreased energy, fatigue or being "slowed down"
  • Difficulty concentrating, remembering or making decisions
  • Insomnia, early-morning awakening or oversleeping
  • Appetite and/or weight loss or overeating and weight gain
  • Thoughts of death or suicide; suicide attempts
  • Restlessness, irritability
  • Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain

Five or more of these symptoms must persist for two or more weeks before a diagnosis of major depression is indicated.

Signs That May Be Associated with Depression in Children and Adolescents:

  • Frequent vague, nonspecific physical complaints such as headaches, muscle aches, stomachaches or tiredness
  • Frequent absence from school or poor performance in school
  • Talk of or efforts to run away from home
  • Outbursts of shouting, complaining, unexplained irritability or crying
  • Being bored
  • Lack of interest in playing with friends
  • Alcohol or substance abuse
  • Social isolation, poor communication
  • Fear of death
  • Extreme sensitivity to rejection or failure
  • Increased irritability, anger or hostility
  • Reckless behavior
  • Difficulty with relationships

While the recovery rate from a single episode of major depression in children and adolescents is quite high, episodes are likely to recur. In addition, youth with dysthymic disorder are at risk for developing major depression. Prompt identification and treatment of depression can reduce its duration and severity and associated functional impairment.

Risk Factors

In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys to develop depression. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.

Other risk factors include:

  • Stress
  • Cigarette smoking
  • A loss of a parent or loved one
  • Break-up of a romantic relationship
  • Attentional, conduct or learning disorders
  • Chronic illnesses, such as diabetes
  • Abuse or neglect
  • Other trauma, including natural disasters

Causes

Some types of depression run in families, suggesting that a biological vulnerability. This seems to be the case with bipolar disorder. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder will have the illness. Apparently additional factors, possibly stresses at home, work or school are involved in its onset.

In some families, major depression also seems to occur generation after generation. However, it can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with changes in brain structures or brain function.

People who have low self-esteem, who consistently view themselves and the world with pessimism or who are readily overwhelmed by stress are prone to depression. Whether this represents a psychological predisposition or an early form of the illness is not clear. Also, a serious loss of a friend or family member, difficult relationship, family problems such as divorce or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological and environmental factors is involved in the onset of a depressive disorder.

Treatment

Treatment for depressive disorders in children and adolescents often involves short-term psychotherapy, medication -- or the combination of these -- and targeted interventions involving the home or school environment. There remains, however, a pressing need for additional research on the effectiveness of psychosocial and pharmacological treatments for depression in youth. While data from adults indicate the need for maintenance treatment after episode recovery to prevent recurrences, the value of such treatment in children and adolescents has yet to be determined through research.

Psychotherapy

Psychotherapy is often used as an initial treatment for milder forms of depression. Many times, psychotherapy accompanied by an early follow-up appointment may help to establish the persistence of depression before a decision is made to try antidepressant medications. Psychotherapies include "cognitive behavioral therapy" and "interpersonal therapy." For moderate to severe forms of depression, especially if persistent, the current evidence supports the use of fluoxetine alone or in combination with cognitive-behavioral therapy.

Many forms of psychotherapy, including some short-term (10- to 20-week) therapies, can help depressed individuals. Talking therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with homework assignments between sessions. Behavioral therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.

Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive-behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate (or increase) the depression. Cognitive-behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.

Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.

Continuing psychotherapy for several months after remission of symptoms may help patients and families consolidate the skills learned during the acute phase of depression, cope with the after-effects of the depression, effectively address environmental stressors and understand how the young person's thoughts and behaviors could contribute to a relapse.

Medication

Research clearly demonstrates that antidepressant medications, especially when combined with psychotherapy, can be very effective treatments for depressive disorders in adults. Using medication to treat mental illness in children and adolescents, however, has caused controversy.

Use of SSRI medications has risen dramatically in the past several years in children and adolescents ages 10 through 19. Some studies show that this increase has coincided with a significant decrease in suicide rates in this age group, but it is not known if SSRI medications are directly responsible for this improvement.

Fluoxetine (also known as Prozac) is the only medication approved by the FDA for use to treat depression in children age 8 and older. The other SSRI medications, such as sertraline, citalopram and paroxetine, and the SSRI-related antidepressant venlafaxine have not been approved for treatment of depression in children or adolescents, though they have been prescribed to children by physicians in "off-label use" -- a use other than the FDA approved use. In recent years, the FDA recommended that paroxetine not be used in children and adolescents for the treatment of major depressive disorder.

Fluoxetine has been shown to be helpful for treating childhood depression in three different clinical trials -- two supported by NIMH and the other supported by the manufacturer of the drug. The trials found that fluoxetine by itself, and even more so when combined with cognitive behavioral therapy, reduced depression for many children better than an inert placebo pill. However, fluoxetine failed to improve depression in at least one third of patients. Also, about one in 10 children experienced adverse side effects such as agitation and mania.

Fluoxetine leads to significant improvement of depression overall. The drug, however, may increase the risk for suicidal behaviors in a small subset of adolescents. As with all medical decisions, doctors and families have to weigh risks and benefits of treatment for each individual patient.

Recently, the FDA adopted a "black box" label warning that antidepressants were found to increase the risk of suicidal thinking and behavior in children and adolescents with major depressive disorder. A black-box warning is the most serious type of warning in prescription drug labeling. The warning also emphasizes that children and adolescents started on SSRI medications should be closely monitored for any worsening in depression, emergence of suicidal thinking or behavior, and, in general, for any unusual changes in behavior -- such as sleeplessness, agitation or withdrawal from normal social situations. This monitoring is especially important during the first four weeks of treatment. SSRI medications usually have few side effects in children and adolescents, but for unknown reasons, can trigger agitation and abnormal behavior in certain individuals.

Medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy, those who are unable to undergo psychotherapy, those with psychosis and those with chronic or recurrent episodes. Following remission of symptoms, continuation treatment with medication and/or psychotherapy for at least several months may be recommended by the psychiatrist, given the high risk of relapse and recurrence of depression. Discontinuation of medications, as appropriate, should be done gradually over six weeks or more.

Sources:

  • National Institute of Mental Health
  • Journal of Affective Disorders
  • Journal of the American Academy of Child and Adolescent Psychiatry
  • National Institutes of Health, U.S. Department of Health and Human Services
  • Annals of Neurology

Last Reviewed: 28 Oct 2005
Last Reviewed By: Laura Stephens