What you should know about depression.
Information supplied by the Johns Hopkins Mood Disorders Center.
Major depression and bipolar disorder often appear for the first time during the teenage years, and early recognition of these conditions will have profound effects on later morbidity and mortality.
Most health professionals today consider depression a chronic illness that requires long-term treatment, much like diabetes or high blood pressure. Although some people experience only one episode of depression, most have repeated episodes of depression symptoms throughout their life.
Signs of depressive disorders in young people often are inappropriately viewed as normal mood swings typical of a particular developmental stage. In addition, healthcare professionals may be reluctant to prematurely label a young person with a mental illness diagnosis. Yet, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social and behavioral development.
At any given time, up to 15 percent of children and adolescents have some symptoms of depression. Five percent of those nine to 17 years of age meet the criteria for major depressive disorder.
By 14 years of age, depressive disorders are more than twice as common in girls as in boys, possibly because of hormonal changes during puberty. Adolescent depressive disorders often have a chronic, waxing-and-waning course and there is a two to fourfold risk of depression persisting into adulthood.
Depression impacts growth and development, school performance and peer or family relationships. It can be fatal. Major depressive disorder is a leading cause of youth suicidal behavior and suicide.
Because mood disorders substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for clinicians who deal with the mental health problems of children and adolescents. The incidence of suicide attempts reaches a peak during the mid adolescent years; the mortality rate from suicide increases steadily through the teenage years.
Suicide is the third leading cause of death in 13- to 19-year-olds, with approximately 6,000 suicide deaths per year. As many as 15 percent of those with depression or bipolar disorder die from suicide each year.
Diagnosis of primary depressive mood disorders require that physicians rule out depression from medical causes, such as endocrine disorders, malignancies, chronic diseases, infectious mononucleosis, anemia, vitamin deficiencies, and from other medications.
The DSM-IV diagnostic criteria for depressive disorders are the same for children and adolescents as they are for adults, with small exceptions stated as notations to the criteria.
The DSM-IV defines a major depressive episode as a syndrome in which at least five of the following symptoms have been present during the same two-week period:
- Depressed mood (for children and adolescents, this also can be an irritable mood)
- Diminished interest or loss of pleasure in almost all activities
- Sleep disturbance
- Weight change or appetite disturbance (for children this can be failure to achieve expected weight gain)
- Decreased concentration or indecisiveness
- Suicidal ideation or thoughts of death
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or inappropriate guilt
Sleep disturbance may manifest as frequently waking up, difficulty in getting up for school, or sleeping during the day. Lack of motivation and lowered energy level could be reflected by missed classes. A significant drop in grade averages can be equated with loss of concentration and slowed thinking. A depressed state can often present as an irritable mood. Loss of appetite could potentially lead to anorexia or bulimia. Substance or alcohol abuse often occurs as an inappropriate means of self-medication.
It's not known specifically what causes depression. As with many mental illnesses, it's thought that a variety of biochemical, genetic and environmental factors may cause depression:
- Biochemical – Some evidence from high-tech imaging studies indicates that people with depression have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes. The naturally occurring brain chemicals called neurotransmitters, which are linked to mood, also may play a role in depression. Hormonal imbalances also could be a culprit.
- Genes – Some studies show that depression is more common in people whose biological family members also have the condition. Researchers are trying to find genes that may be involved in causing depression.
- Environment – Environment is also thought to play a causal role in some way. Environmental causes are situations in your life that are difficult to cope with, such as the loss of a loved one, financial problems and high stress.
A thorough understanding of the mental health resources in the community is extremely important because the ability to communicate and deal with adolescents is not universally or equally shared.
More than 70 percent of children and adolescents with depressive disorders or other serious mood disorders do not receive appropriate diagnosis and treatment.
Although less common, bipolar disorder needs to be considered when a child or adolescent has significant mood changes. In 40 percent of children and adolescents with bipolar disorder, the illness begins with a major depressive episode.
Treatment for depressive disorders in children and adolescents often involves a combination of psychotherapy and medication, as well as targeted interventions involving the home or school environment. Any issues of alcohol and substance abuse must also be addressed. Formal family therapy may be required to deal with specific problems or issues.
Research 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.
Many doctors have understandably been reluctant to treat young people with medications because, until recently, little evidence was available about the safety and efficacy of these drugs in youth.
In the last few years, researchers have been able to conduct randomized, placebo-controlled studies with children and adolescents. Some of the newer antidepressant medications, specifically the selective serotonin reuptake inhibitors (SSRIs), have been shown to be safe and efficacious for the short-term treatment of severe and persistent depression in young people, although large scale studies in clinical populations are still needed. So far, there are two controlled studies showing efficacy with fluoxetine and paroxetine.
The choice of an antidepressant also may be guided by patient or family history of antidepressant response; side-effect profile; and drug-drug, drug-disease, and drug-food interactions.
Evidence suggests that early intervention for depression in children can improve long-term outcomes. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies.
A child psychiatric consultation is helpful for children with severe recurrent depression or treatment-resistant depression.