||Depression in Children and Adolescents
New Fact Sheet For Physicians From The NIMH
Diagnosis and treatment of depression in children and adolescents is a major challenge. Many children as well as adolescents suffer from depression, a disorder that can have far reaching effects on the functioning and adjustment of young people. Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is over; in adolescents there is also an increased risk for substance abuse and suicidal behavior. Unfortunately, major depressive disorder—also known as unipolar depression—often goes undiagnosed. Studies show that signs of major depressive disorder in young people are frequently viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely "label" a young person with a mental illness diagnosis. Yet early diagnosis and treatment are important; between 80 and 90 percent of people with depression—even the most serious forms—can be helped.
The scientific literature on treatment of children and adolescents with depression is far less extensive than that concerning adults. A handful of large-scale studies—mostly conducted in the last four to five years—has evaluated the short-term efficacy and safety of treatments for depression in children and adolescents. Larger treatment trials are needed to determine which treatments work best for which youth. Studies are also needed on how to best incorporate these treatments into primary care practice.
Given the challenging nature of the problem, it is usually advisable to involve a child psychiatrist or psychologist in the evaluation, diagnosis, and treatment of a child or adolescent in whom depression is suspected.
This fact sheet, prepared by the National Institute of Mental Health (NIMH), the lead Federal agency for research on mental disorders, summarizes some of the latest scientific findings on child and adolescent depression and lists resources where family physicians can obtain more information.
Scope of the Problem
An NIMH-sponsored epidemiological study of 9- to 17-year-olds estimates that the prevalence of any depression is more than 6 percent, with 4.9 percent having major depression.1 In addition, research has found that depression onset is occurring earlier in life. A study reported in the Journal of the American Medical Association suggests that early onset depression often persists, recurs, and continues into adulthood.3 Depression in childhood may also predict more severe illness in adult life.4 Depression in young people is often accompanied by psychological or somatic symptoms, behavioral manifestations, or other disorders, such as anxiety disorders. It also often occurs in conjunction with illnesses such as diabetes.
Suicide. Depression in children and adolescents is associated with an increased risk of suicidal behaviors. This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.5 In 1997, suicide was the third leading cause of death in 10- to 24-year-olds.6 NIMH research indicates that among children and adolescents who develop major depressive disorder, as many as 7 percent may commit suicide in the young adult years.3 Consequently, it is important for doctors and parents to take all threats of suicide seriously.
NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limiting young people's access to lethal agents—including firearms7 and medications—may hold the greatest suicide prevention value.
The diagnostic criteria and key defining features of depression in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder are more difficult in youth for several reasons. The way symptoms are expressed varies with the developmental stage of the youngster. In addition, depressed children and young adolescents may have difficulty in properly identifying and describing their internal emotional or mood states. For example, young people may not complain about how bad they feel and may instead act moody and cranky, which may be interpreted by others as misbehavior or disobedience. Research also shows 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 or irritable mood
- Loss of interest in activities once enjoyed
- Significant change in appetite or body weight
- Difficulty sleeping or oversleeping
- Psychomotor agitation or retardation
- Loss of energy
- Feelings of worthlessness or inappropriate guilt
- Difficulty concentrating
- Recurrent thoughts of death or suicide
Five or more of these symptoms must persist for 2 or more weeks before a diagnosis of depression is indicated.
Ways Symptoms May Manifest in Children and Adolescents
- Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomachaches or tiredness
- Frequent absences 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
- Among adolescents, 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
There are several tools that are useful for screening children and adolescents for depression. They include the Children's Depression Inventory (CDI)9 for ages 7 to 17; and, for adolescents, the Beck Depression Inventory10 and the Center for Epidemiologic Studies Depression (CES-D) Scale.11 When these are positive, further evaluation, which may include interviews with the child, parents, and collateral informants, such as teachers and social services personnel, is warranted.
Among children, boys and girls appear to be at equal risk for developing depression. Adolescent girls, however, may be more at risk than their male counterparts.13 Children who develop major depression are likely to have a family history of the disorder, often a parent who experienced depression at an early age.14 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. In addition, teen cigarette smoking is associated with depression.15
Other risk factors include:16
- A loss of a parent or loved one
- Attentional, conduct or learning disorders
- Chronic illnesses, such as diabetes
- Abuse or neglect
- Other trauma, including natural disasters
The last decade has spawned advances in treatment options for young people with depression. Treatment often combines short-term psychotherapy, medication, and targeted interventions involving the home or school environment. There remains, however, a pressing need for additional research on treatments for depression in children and adolescents, including medications as well as psychotherapies.
In general, to prevent the recurrence of depression, it is recommended that treatment be continued for all patients for at least 6 months after the remission of symptoms.
Psychotherapy. Recent research shows that certain types of short-term psychotherapy, particularly cognitive-behavioral therapy (CBT), can help relieve depression in children and adolescents.12,18,19 CBT is based on the premise that depressed patients have cognitive distortions in their views of themselves, the world, and the future. CBT, designed to be a time-limited therapy, focuses on changing these distortions. An NIMH-supported study on treating major depression in adolescents, for example, found that CBT resulted in a rate of remission of nearly 65 percent, a higher rate than either supportive therapy or family therapy. CBT also resulted in a more rapid treatment response.20
Related forms of focused, problem-solving psychotherapy that target interpersonal features of depression also appear to be effective.21
Continuing psychotherapy after remission of symptoms helps 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 contribute to a relapse. If the patient is taking antidepressants, continued psychotherapy may also help to promote medication compliance.12
Medication. Research clearly demonstrates that antidepressant medications, especially when combined with psychotherapy, can be very effective treatments for depressive disorders in adults.22 Using medication to treat young people, however, has caused controversy. Many doctors have been understandably reluctant to treat depressed children and adolescents with psychotropic medications because, until fairly recently, little evidence was available about the effects of antidepressants on young people.
In the last few years, however, researchers have been able to conduct randomized, placebo-controlled studies on children and adolescents. Some of the newer antidepressant medications, specifically the selective serotonin reuptake inhibitors (SSRIs), have been shown to be safe and effective 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 controlled studies showing good results for fluoxetine and paroxetine.23,24
It is important to note that available studies do not support the efficacy of tricyclic antidepressants (TCAs) for this age group.25 In addition, a recent review of the role of TCAs in children and adolescents cautions that "the future therapeutic role of TCAs for children and adolescents need to be seriously weighed against lethality of overdose, the unresolved issue of possible sudden unexplained death, and the availability of safer and easier to monitor medications."26
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.
To develop more science-based information on the effectiveness of both medication and psychotherapeutic treatments for adolescent depression, NIMH has started a large, controlled clinical trial at 9 sites that is being coordinated by Duke University. The sites, which may be good sources of information for family physicians, are located at New York University/New York State Psychiatric Institute, Wayne State University, University of Chicago, University of Nebraska-Creighton, University of Oregon, University of Pennsylvania, University of Texas Southwestern, Carolinas Medical Center (Charlotte, NC), and The Johns Hopkins University.
Talking With Parents
One of the most important things family physicians can do is to reassure parents that children can be effectively treated for depression. Parents are likely to be asked to be involved in psychotherapeutic treatments to help identify major sources of stress for their child or adolescent and to help the family develop better ways of coping with life situations. Parents may be reluctant to agree to drug treatment when it is needed because of the newness of data on medications to treat the disorder in young people and because of sensational and erroneous media coverage linking antidepressants to violent activity or suicide. Physicians can calm these fears by informing parents about the latest studies on the effectiveness and safety of current medications. They can also point to the recommendation of the American Academy of Child and Adolescent Psychiatry that medication can be an effective part of the treatment for depression, especially when it is used as part of a comprehensive treatment plan that includes psychotherapy.12
Other Types of Depression In Children and Adolescents [BOX]
Although rare in young children, bipolar disorder27—also known as manic-depressive illness—can appear in both children and teenagers. Bipolar disorder involves unusual shifts in mood, energy, and functioning. It may begin with either manic or depressive symptoms. It is more likely to affect the children of parents who have the disorder.
Unlike adults, whose symptoms are acute and episodic, young children often experience rapid mood swings and cycle from depression to mania several times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be elated or euphoric. Bipolar disorder accounts for a large proportion of children's psychiatric hospitalizations. Some 20 percent of adolescents with major depression develop bipolar disorder within 5 years of the onset of depression.13
Teenagers with bipolar disorder display a combination of extremely manic and depressive moods. Highs may alternate with lows, or, for some youths, the moods may change so quickly that the adolescent feels both extremes at almost the same time.
Symptoms of bipolar disorder often can be difficult to distinguish from other problems of childhood and adolescence. For example, while irritability and aggressiveness can indicate bipolar disorder, they can also be symptoms of depression or conduct disorder. Among teenagers, irritability and aggressiveness could indicate more common adolescent problems such as drug abuse, delinquency, attention deficit hyperactivity disorder (ADHD), or a less frequent disorder, schizophrenia. However, any child who appears to be depressed and exhibits ADHD-like symptoms that are very severe, with excessive temper outbursts and mood changes, should be evaluated to rule out bipolar disorder, particularly if there is a family history of bipolar disorder. This evaluation is necessary especially since psychostimulants, often prescribed for ADHD, may worsen manic symptoms. There is also limited evidence suggesting that some of the symptoms of ADHD may be a forerunner of full-blown mania.
Bipolar Disorder: Manic Symptoms28,8
- Severe changes in mood; unusual happiness or silliness, or extreme irritability
- Overly-inflated self-esteem
- Great energy increase; ability to go with very little or no sleep for days without tiring
- Increased talking—talks too much, too fast; changes topics too quickly; cannot be interrupted
- Distractibility—attention moves constantly from one thing to the next
- Disregard of risk
Bipolar Disorder: A Warning about Antidepressants
There is some evidence that using antidepressants to treat a child with depression who has bipolar disorder may induce manic symptoms.27 While it can be hard to determine which young patients will become manic, there is a greater likelihood among children who have a family history of bipolar disorder. Family physicians seeing a child who may be depressed and who has a family history of bipolar disorder may want to consult with a child psychiatrist. Family practitioners should also be aware of the signs and symptoms of mania so that they can educate families on how to recognize these immediately.
Dysthymic disorder (or dysthymia)
This less severe yet typically more chronic form of depression is diagnosed when depressed mood persists for at least one year in children or adolescents, and is accompanied by at least two of the symptoms of major depression.8 Dysthymia often precedes major depressive disorder. Treatment of the child or adolescent with dysthmia may prevent the deterioration to more severe illness.12
Dr. Frank V. deGruy, III, MD, MSFM, Chairman, Department of Family Medicine, University of Colorado Health Sciences Center, advised NIMH on the development of this fact sheet.
National Institute of Mental Health
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American Academy of Child and Adolescent Psychiatry
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American Psychiatric Association
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American Psychological Association
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National Depressive and Manic-Depressive Association
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National Mental Health Association
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1Shaffer, D., et al. "The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, Acceptability, Prevalence Rates and Performance in the MECA Study." J Am Acad Child Adolesc Psychiatry. 35(7):865-877, 1996.
3Weissman, M., et al. "Depressed Adolescents Grown Up." JAMA. 281:1701-1713, 1999.
4"Depression Research at the National Institute of Mental Health." Fact Sheet, NIMH, 1999. http://www.nimh.nih.gov/publicat/depresfact.cfm
5Shaffer, D., and Craft, L. "Methods of Adolescent Suicide Prevention." J Clin Psychiatry. 60(suppl 2):70-74, 1999.
6"Ten Leading Causes of Death, United States, 1997." CDC. http://www.cdc.gov/ncipc/osp/states/101c97.htm
7Brent, D., et al. "The Presence and Accessibility of Firearms in the Homes of Adolescent
Suicides. A case-control study." JAMA. 266:2989-2995, 1991.
8American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Primary Care Version. Washington, DC: American Psychiatric Association, 1995.
9Developed by Kovacs, M. Available from Multi-Health Systems (MHS, Inc.), 65 Overlea Blvd., Suite 10,Toronto, Ontario M4H1P1 Canada; phone: 800-456-3003.
10Developed by Beck, A. Available from Psychological Corporation, 555 Academic Court, San Antonio, TX 78204; phone: (210) 299-1061.
11Developed by NIMH. Available from NIMH, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663; phone: (301) 443-4513.
12"Summary of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders." AACAP, 1998. http://www.aacap.org/clinical/Depres~1.htm
13Birmaher, B., et al. "Childhood and Adolescent Depression: A Review of the Past 10 Years. Part I." J Am Acad Child Adolesc Psychiatry. 35(11):1427-1439, 1996.
14Weissman, M., et al. "Offspring of depressed parents." Arch Gen Psychiatry. 54:932-940, 1997.
15Lewinsohn, P.M., et al. "Major Depressive Disorder in Older Adolescents: Prevalence, Risk Factors, and Clinical Implications." Clin Psychol Rev. 18(7):765-794, 1998.
16"The Depressed Child." Facts for Families Fact Sheet Series, AACAP, 1998. http://www.aacap.org/publications/factsfam/depressd.htm
17Kovacs, M. "Psychiatric Disorders in Youths with IDDM: Rates and Risk Factors." Diabetes Care. 20 (1):36-44, 1997.
18Jayson, D., et al. "Which Depressed Patients Respond to Cognitive-Behavioral Treatment?" J Am Acad Child Adolesc Psychiatry. 37:35-39, 1998.
19Reinecke, M., and Dubois, D., "Cognitive-Behavioral Therapy of Depression and Depressive Symptoms During Adolescence: A Review and Meta-Analysis." J Am Acad Child Adolesc Psychiatry. 37:26-34, 1998.
20Brent, D., et al. "A Clinical Psychotherapy Trial for Adolescent Depression Comparing Cognitive, Family, and Supportive Therapy." Arch Gen Psychiatry. 54(9):877-885, 1997.
21Kovacs, M., and Bastiaens, L: "The Psychotherapeutic Management of Major Depressive and Dysthymic Disorders in Childhood and Adolescence: Issues and Prospects." in The Depressed Child and Adolescent: Developmental and Clinical Perspectives. I. M. Goodyer, ed. New York, NY: Cambridge University Press, 1995.
22Clinical Practice Guideline, Number 5. "Depression in Primary Care: Volume 1. Detection and Diagnosis (AHCPR Publication No. 93-0550); and Volume 2. Treatment of Major Depression (AHCPR Publication No. 93-0551)." U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, 1993.
23Emslie, G. "A Double-Blind, Randomized, Placebo-Controlled Trial of Fluoxetine in Children and Adolescents with Depression." Arch Gen Psychiatry. 54:1031-1037, 1997.
24Keller, M., "Paroxetine and Imipramine in the Treatment of Adolescent Depression." Presented at the 151st Annual Meeting of the American Psychiatric Association, Toronto, June 1998.
25Geller, B., et al., "Pharmacokinetically Designed Double-Blind Placebo-Controlled Study of Nortriptyline in 6- to 12-Year-Olds with Major Depressive Disorder." J Am Acad Child Adolesc Psychiatry. 31:34-44, 1992.
26Geller, B., et al., "Critical Review of Tricyclic Antidepressant Use in Children and Adolescents." J Am Acad Child Adolesc Psychiatry. 38(5):513-516, 1999.
27McClellan, J., and Werry, J. "Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder." J Am Acad Child Adolesc Psychiatry. 36(1):138-157, 1997.
28"Manic-Depressive Illness in Teens." Facts for Families Fact Sheet Series, AACAP, 1997. http://www.aacap.org/publications/factsfam/bipolar.htm
National Institute of Mental Health
Office of Communications and Public Liaison
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
NIH Publication No. 00-4744
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