Childhood and Adolescent Depression

Depression in children and adolescents can be difficult to diagnose because their normal behavior is often marked by mood swings and negative thoughts. In many adolescents, a depressed mood is common because of the normal maturation process, the stress associated with it, the influence of sex hormones, and independence-related conflicts with parents.

Sadness or moodiness in children and adolescents might also be a reaction to a disturbing event, such as the death of a friend or relative, a breakup with a boyfriend or girlfriend, or a failure at school. But a persistent bad mood, faltering school performance, troubled relationships with family and friends, and other negative behaviors might indicate depression.

Russell Scheffer, MD, Associate Professor of Psychiatry and Behavioral Medicine (Pediatrics) at the Medical College of Wisconsin, practices at the Child Psychiatry Center at Children's Hospital of Wisconsin. He says that children and adolescents might have a hard time telling parents, caregivers, and physicians that they are depressed. "They are not very likely to come in complaining that they're depressed," says Dr. Scheffer. "They usually complain about somatic (physical) symptoms such as headaches or stomach aches."

If children have never been depressed or witnessed a family member's depression, he says, they probably won't recognize their own. "They have a 'bad feeling', which we call dysphoria, but they don't know what it is."

Warning Signs
In addition to somatic symptoms, child and adolescent depression can manifest itself in several ways, says Dr. Scheffer. "A drop-off in school performance, decreased social interactions, a lack of interest in things they used to be interested in, difficulty concentrating, or in some cases, thoughts of death or suicide - these are classic signs of depression." In young children, depression can often look like irritability or boredom, and in adolescents, there might be self-medication in the form of drug or alcohol abuse.

Feelings of worthlessness or excessive guilt are often present as well. "They feel like they're not a worthwhile person," says Dr. Scheffer. "If we've done something bad, we're supposed to feel a little guilty, but they might start feeling guilt that is completely unwarranted."

Certain sleep disorders could also be related to depression, says Dr. Scheffer. "Middle and terminal insomnia - waking up in the middle of the night or very early in the morning and not being able to go back to sleep - is common in adolescent depression," he says.

Weight loss can occur in some people, says Dr. Scheffer. "It's typically a decreased appetite. In atypical depression, however, they will eat more and sleep more, which leads to weight gain."

Fatigue and loss of energy can be an issue, often accompanied by decreased motor activity. In other words, "The kinds of activities they used to do, now wear them out," says Dr. Scheffer.

It's important to note that children and adolescents can have symptoms of depression, but not have depression. "If you have the symptoms but you feel fine, you don't have a disorder," says Dr. Scheffer. There are also other medical reasons for symptoms to occur, which have nothing to do with depression.

If a parent or caregiver sees problematic signs of depression, says Dr. Scheffer, "getting an evaluation is the most important thing." An initial evaluation might be done by the child's primary care physician, a mental health worker, a psychologist, or a therapist. "Unfortunately," he says, "many child psychiatrists have waiting lists several months long, and by that time the child could have profound depression if he or she hasn't been treated."

Treatment
Dr. Scheffer says that for a mild to moderate depression, where the child or adolescent patient is clearly not suicidal but is having some level of dysfunction, psychotherapy is the most helpful treatment. "The two main kinds of psychotherapy are cognitive and behavioral therapy (CBT) and interpersonal therapy," he says.

"CBT looks at the ways we process information," says Dr. Scheffer. "When people are depressed, they look at the world in a negative way. CBT focuses on changing those negative thoughts, behaviors, and feelings." Interpersonal therapy takes advantage of the fact that depressive symptoms tend to occur most often within interpersonal relationships. "It focuses on ways to help those relationships get better, and subsequently, the patient might feel better as well."

In more severely depressed children and adolescents, large studies in the US and UK in recent years have shown that CBT treatment alone was about as effective as a placebo. "However, medications alone were quite effective," says Dr. Scheffer, "and there was a slightly better outcome when they added CBT to medications."

All this translates into two basic sets of guidelines for parents and caregivers, says Dr. Scheffer: "For a mild-to-moderately depressed patient, therapy first and medication second; and for a more severely depressed patient, medication for sure and therapy if they can get it."

Suicide Risk is Controversial
Regarding the alleged risk of suicide in children taking antidepressants, Dr. Scheffer says, "It's absolutely wrong for people to think that children began killing themselves when they started on antidepressants. In thousands of children in several studies, nobody killed themselves."

The controversy might have come from the methods of the studies, he says. "The patient entering these studies had to be non-suicidal on that day. They might have been suicidal the day before or the day after, but on this day, they weren't. If they got medicine, they had a 4% risk of developing suicidal thoughts during the study. If they got placebo, there was a 2% chance that they would develop suicidal thoughts."

The children and adolescents in the studies were asked about thoughts of suicide before and after taking antidepressants. "Statistically, these dramatically improved during the course of the studies," says Dr. Scheffer. "So even if they entered the study saying they were not suicidal that day, if they had suicidal thoughts previous to the first day of the study or during the study, those dramatically improved."

There might be other reasons for suicidal thoughts too, says Dr. Scheffer. "There is a side effect of antidepressants called akathesia, a sense of motor restlessness, a feeling that you have to keep moving. If it's severe, patients might try to commit suicide just to escape that feeling."

In addition, people with depression are most vulnerable to suicidal thoughts just when they start to recover. "The idea is that perhaps your cognition is still somewhat depressed - you're still thinking negatively - but now you have the energy to do something about it," says Dr. Scheffer.

Dr. Scheffer says that a Columbia University study recently looked at census information, and proved very clearly that in the US, the higher the number of prescriptions for antidepressants, the lower the suicide rate. He says that between the end of World War II and the early 1990s, "the suicide rate went up every single year. Then, in the early 1990s, selective serotonin reuptake inhibitor medications (SSRIs) came out, and the suicide rate came down for the first time in 50 years. In 2004, when the controversy began, many patients and their physicians abandoned these drugs, and the suicide rate went back up. So there is a clear consequence of not treating depression."

Primary Care Physicians Also Participate
Dr. Scheffer says it's important for primary care physicians to be willing to help treat childhood and adolescent depression. "If it's left to the small number of child psychiatry providers, it often doesn't happen," he says.

To that end, the Child Psychiatry Center at Children's Hospital has developed a program to help primary care physicians better serve their patients. "We surveyed primary care physicians and found that they needed help with diagnosis, and that they wanted user-friendly treatment guidelines. What we've done at Children's is bundle this together. We do a thorough diagnostic evaluation on the child, and return them with user-friendly treatment guidelines for the primary care physician to implement."

Physicians receive a list of options regarding treatment possibilities. "We don't tell them absolutely how to treat the child, but we give them a list of options such as typical dosing ranges for medications."

Overall, Dr. Scheffer says that the most important thing to remember about depression at any age is that it's treatable with therapy and/or medication. "About 20% of patients who have had major depression in their lifetime will commit suicide," he notes. Recognizing and treating the problem before it becomes that serious is essential.

P. J. Early
HealthLink Contributing Writer

This article includes information from the National Institutes of Health

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.