Kids can get depressed and disorders ranging from major depression to bipolar disorder are increasingly diagnosed in children, whose symptoms are especially likely to include irritability. Psychotherapy is often highly effective, although drug treatment has been prescribed.
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. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life. Dysthymia involves long-term (two years or longer) but less severe 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.
Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include: Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions. Seasonal affective disorder (SAD) is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer.
The diagnostic criteria and key defining features of major depressive disorder in children and adolescents are the same as they are for adults. Research has shown that childhood depression often persists, recurs, and continues into adulthood, especially if it goes untreated. The presence of childhood depression also tends to be a predictor of more severe illnesses in adulthood.
However, recognition and diagnosis of the disorder may be more difficult in youth for several reasons. A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to accurately diagnose a young person with depression.
Before puberty, boys and girls are equally likely to develop depressive disorders. By age 15, however, girls are twice as likely as boys to have experienced a major depressive episode.
Depression in adolescence comes at a time of great personal change: when boys and girls are forming an identity distinct from their parents, grappling with gender issues and emerging sexuality, and making decisions for the first time in their lives. Depression in adolescence frequently co-occurs with other disorders such as anxiety, disruptive behavior, eating disorders, or substance abuse. It can also lead to increased risk for suicide.
Symptoms of Major Depressive Disorder Common to Adults, Children and Adolescents:
For DSM-5 diagnosis of Major Depressive Disorder five or more of these symptoms must persist for two or more weeks, with two of the required five symptoms needing to be (1) depressed mood or (2) loss of interest or pleasure. The five (or more) symptoms cause distress or impairment in socializing, working, or other important areas of functioning (e.g. hygiene).
1. Feelings of depression (such as sadness, emptiness, hopelessness) or irritable mood most of the day lasting for nearly every day.
2. Noticeably less excitement for or during activities of interest or pleasure in most activities lasting for a majority of the day, nearly every day.
3. Significant and unexpected fluctuation in weight (loss or gain) that can have some children unable to meet developmental expected weight gain, or decrease or increase in appetite nearly every day.
4. The inability to sleep/fall asleep or remain sleeping (insomnia) or having too much sleep or persistent feelings of sleepiness (hypersomnia) nearly every day.
5. Increases of purposeless physical activity (e.g., restlessness, pacing, rapid talking, tapping fingers/feet) or decreases in physical activity or the want to pursue physical activity nearly every day (observed by others, and do not account for subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or inappropriate guilt nearly every day.
8. Unusual problems with the ability to think or concentrate, or excessive indecisiveness, nearly every day.
9. Frequent reoccurring thoughts of death (not just fear of dying), suicidality (thoughts about suicide, wanting to commit suicide, planning how to suicide, and talking about suicide), suicidal thoughts without a specific plan, or a suicide attempt or a specific plan for suicide.
It is important to understand that many of the symptoms listed above may manifest in response to a significant loss (bereavement, financial ruin, a serious medical illness or disability). Although responses such as the symptoms listed above may be understandable or possibly even appropriate to the loss, the presence of a major depressive episode should be carefully considered with consideration based on the individual’s history and the cultural norms for the expression of loss.
Signs That May Be Associated with Depression in Children and Adolescents:
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.
There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.
Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. In addition, important neurotransmitters—chemicals that brain cells use to communicate—appear to be out of balance. But these images do not reveal why the depression has occurred.
Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.
In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.
Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.
The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview, and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer the patient to a mental health professional.
The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should discuss any family history of depression, and get a complete history of symptoms—when they started, how long they have lasted, their severity, and whether they have occurred before and if so, how they were treated. He or she should also ask if the patient is using alcohol or drugs, and whether the patient is thinking about death or suicide.
Once diagnosed, a person with depression can be treated with a number of methods.
The most common treatment for depressive disorders in children and adolescents involves psychotherapy and medication, as well as targeted interventions involving the home or school environment.
An NIMH-funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option. Other NIMH-funded researchers are developing and testing ways to prevent suicide in children and adolescents, including early diagnosis and treatment, and a better understanding of suicidal thinking.
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.
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.
Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—have been proven effective in treating depression. CBT helps people change negative styles of thinking and behaving that may contribute to depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.
Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings.
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.
Antidepressant medications, especially when combined with psychotherapy, can be very effective treatments for depressive disorders in adults. Use of SSRI medications has risen dramatically in the past several years in children and adolescents ages 10 through 19.
Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.
The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta).
For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, to prevent a relapse of the depression. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit-forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.
In 2005, the FDA adopted a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning, the most serious type of warning on prescription drug labeling, emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. This warning advises additionally that families and caregivers be told of the need for close monitoring and report any changes to the physician.
Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.
Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.
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 of 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.