Depressive Disorders (Children and Adolescents)
Children can get depressed, and disorders ranging from major depression to bipolar disorder are increasingly diagnosed in children and adolescents. Psychotherapy is often a highly effective form of treatment, and depending on the severity of the case, medication may also be prescribed.
Depressive disorders include major depressive disorder (unipolar depression); persistent depressive disorder (formerly called dysthymic disorder, this is a chronic, mild depression); disruptive mood dysregulation disorder (chronic, severe irritability); and premenstrual dysphoric disorder (depressed mood, irritability and anxiety during the pre-menstrual period). Bipolar disorders (manic-depression) also have a depressive component. These disorders can have far-reaching effects on the functioning and adjustment of young people.
Major depression is manifested by a combination of symptoms (see symptoms 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.
Persistent depressive disorder involves long-term (two years or longer) but less severe symptoms that keep an individual from functioning well or from feeling good. Many people with persistent depressive disorder 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, such as severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but typically 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.
Premenstrual dysphoric disorder can occur at any time following the first occurrence of menstruation.
Disruptive mood dysregulation disorder has an onset before the age of 10, and consists of chronic, severe, persistent irritability. Children with this condition have frequent temper outbursts that include verbal rages and/or physical aggression towards people or property. Disruptive mood dysregulation disorder is more common than bipolar disorder before adolescence, and symptoms tend to decrease as an adolescent moves into adulthood.
Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. They include depression with psychotic features, 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 depressive symptoms during the winter months, when there is less natural sunlight. This type of 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 illness 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 and adolescents 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; boys and girls are forming identities distinct from those of their parents, grappling with gender issues and emerging sexuality, and making independent 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:
- Persistent feelings of sadness, anxiety, or feeling "empty"
- 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 feeling "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
Many of the symptoms listed above may manifest in response to a significant loss (bereavement, financial ruin, a serious medical illness or disability). Although the presence of these symptoms may be understandable or possibly even appropriate given the loss, the presence of a major depressive episode should be carefully considered 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:
- Frequent vague, nonspecific physical complaints such as headaches, muscle aches, stomach aches, 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 persistent depressive disorder are at risk for developing major depression. Early 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 is a treatable disorder, even in the most severe cases. 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. The doctor 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. Talk 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 psychotherapy—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 interpersonal relationships that may cause their depression or make it worse.
Psychodynamic therapies, which are sometimes used to treat depression, 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 past 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.
A popular category of antidepressant medication is 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 additionally advises that families and caregivers be told of the need for close monitoring and to report any changes to the physician.
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.
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.
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.
- National Institute of Mental Health
- National Institutes of Health, U.S. Department of Health and Human Services
- American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
- Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83.
- March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807-820.
- Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry, 2000; 57: 21-27.
- Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. Journal of the American Medical Association, 2007; 297(15): 1683-1696.
Last reviewed 03/05/2018