January 16, 2019

Intro to Depression

By Mihai Simionescu MD By MS
Complexity rating Intermediate
Evidence Opinion
Read time 15 minutes

How frequent is depression in children and adolescents?

  • At any point in time 1–2% of the children and 3–8% of adolescents suffer from one form of depression.
  • By the end of adolescence around 20% (one in five) of all people had depression.
  • Until puberty boys and girls have the same risk of depression. In adolescence girls are 3(three) times more likely to be depressed.

Risk Factors for Depression

Genetic

  • Depression tends to run in families. Around 50% of the risk for depression may be inherited.
  • It is more likely that adolescent depression is inherited.
  • Young children’s depression may be more likely related with stress in their lives.

Familial/Environmental Risk Factors

  • Are as important as the genetic factors
  • One or both parents are depressed or anxious
  • Somebody close passed away like a sibling, parent, or a close friend.
  • There are a lot of problems in the family: parent has legal problems, parent is abusing alcohol or drugs, the parents disagree a lot, they fight between themselves, there are in conflicts with the child.
  • The child has been neglected or abused.

Symptoms of Depression common for Adults, Children and Adolescents

  • Frequent sadness, tearfulness, crying
  • Increased irritability, anger, or hostility
  • Decreased interest in activities; or inability to enjoy previously favorite activities
  • Significant change in appetite or body weight
  • Difficulty sleeping or oversleeping
  • Agitation or sluggishness
  • Low energy or tiredness
  • Difficulty concentrating
  • Low self esteem and guilt
  • Feelings of worthlessness, hopelessness or inappropriate guilt
  • Thoughts or expressions of suicide or self destructive behavior

Possible signs of Depression in Children and Adolescents

  • Frequent complaints of physical illnesses such as headaches and stomachaches
  • Frequent absences from school or poor performance in school
  • Social isolation, poor communication
  • Being bored
  • Extreme sensitivity to rejection or failure
  • Difficulty with relationships
  • Fear of death
  • Outbursts of shouting, complaining, unexplained irritability, or crying
  • Talk of or efforts to run away from home
  • Reckless behavior
  • Alcohol or substance abuse

Types of Depression

  • Adjustment disorders with depressed mood – depression that occurs in response to a clear problem or issue; usually relatively mild
  • Depression Not Otherwise Specified – mild depression
  • Dysthymic disorder – chronic depression that lasts a minimum of one year.
  • Major depressive Disorder – numerous symptoms of depression, usually moderate or severe
  • “Double depression” – when the child has both Dysthymic Disorder and Major Depression

Many times another disorder is present in addition to depression

  • Anxiety – usually starts before the depression and continues with it.
  • ADHD – children with ADHD have an increased risk of depression
  • Alcohol, drug, and tobacco abuse – sometimes it is the depression that will open the path for substance abuse sometimes is the other way around with the depression starting later
  • Conduct disorder – severe behavioral problems

How long does it last?

  • Most of the times 3 to 8 months
  • About 20% of adolescents will have chronic depression lasting 2 or more years

Longer duration of depression is more likely if…

  • The child has another depressive disorder (for example Dysthymic disorder )
  • The child has another psychiatric disorder (for example anxiety disorder or substance abuse)
  • The depression was more severe to start with
  • The child has now or had in the past suicidal ideation or behavior
  • The parent had chronic depression
  • There are high levels of family conflict

A child with history of depression has a high risk of getting depressed again in the future

  • This risk is about 30-70% in the following 5 years.

The risk of getting depressed again is higher if…

  • The parent developed a mood disorder at an early age
  • The depressive symptoms did not quite went away the first time
  • The child has peer or social problems (isolated, rejected, lonely etc.)
  • There is history of sexual abuse
  • There is a lot of family conflict.

Having depression increases risks for other disorders

  • 10-20% of all depressed children may end up having Bipolar Disorder.
  • This may happen especially:
    • if there is family history of bipolar disorder
    • if the child becomes activated, agitated when given an antidepressant
    • if he or she has psychotic symptoms like hallucinations and delusions.
  • In Bipolar Disorder the symptoms of Depression occur at the same time or take turns with symptoms of Mania.

Bipolar Disorder: Manic Symptoms

  • Severe changes in mood – extremely irritable or overly silly
  • Grandiosity – may act as if he or she has special powers or special rights
  • Increased energy
  • Agitation or increased goal-directed activity
  • Decreased need for sleep – able 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- excessive involvement in risky behaviors or activities
  • Hypersexuality- increased sexual thoughts, feelings, or behaviors; use of explicit sexual language

Treatments for Depression

Psychotherapy
Parents often prefer to try psychotherapy before considering medications. Psychotherapy can be helpful to children and may be all that is necessary to help them sort out their feelings and learn the skills they need to cope with life’s stresses.

Cognitive-behavioral therapy
Children and adolescents with depression have certain characteristic thought patterns, called cognitive distortions, which give them a skewed perception of the world around them. During cognitive-behavioral therapy, the therapist works with the patient to help them recognize their dysfunctional thoughts and to change them to a more realistic perspective.

Interpersonal therapy
Focuses on interpersonal relationships and coping with conflict

Family therapy
Focuses on the importance of family relationships in psychological health

Play therapy
Makes use of children’s natural tendency to play in order to help them work through their inner conflicts and anxieties.

Medications

The FDA (Food and Drug Administration) requires that all antidepressant drugs be labeled with a boxed warning regarding the increased risk of suicidal thoughts and behaviors in children and adolescents. Data from 24 different antidepressant trials involving 4,400 patients showed that during the first few months of treatment the risk for suicidality was double that for those receiving only a placebo. No completed suicides occurred during the trials.

Does this mean that your child should avoid antidepressants? Not necessarily. The risk of suicidal thoughts and feelings is still low. Parents should keep in mind that untreated depression can also lead to suicidal feelings. The expert opinion at this point is that the benefits of antidepressants still outweigh the risks.

The only antidepressant that is currently approved for major depression in children is Prozac (Fluoxetine). Prozac, Zoloft, Luvox and Anafranil are approved for OCD in children. This does not necessarily mean that other drugs are less safe. It simply means that those drugs have not been adequately tested for pediatric use.

If you start your child on an antidepressant

  • You need to monitor your child for any worsening of symptoms, agitation, irritability, suicidality or changes in behavior especially the first month of treatment.
  • You should be able to stay in close contact with your healthcare provider about any changes in your child that you observe.
  • Do not stop giving your child his medication without your physician’s advice and supervision. Your child can experience discontinuation symptoms if his medication is stopped too quickly.
  • Increased attention is necessary not only at the beginning of the treatment, it is also necessary to during increases or decreases in the dose.

Which Is Best, Psychotherapy or Medication?

Depending on the severity of your child’s depression and its causes, therapy alone, medication alone, or therapy combined with medications may be recommended. Generally speaking, a combination of both will get the best results. An antidepressant may help your child begin to feel better. But, the negative thought patterns which lead to depression may still remain. Therapy will help him alter these thought patterns and better cope with stressors in his life that contribute to his depression.

Resilience

Is the capacity that promote children’s effective functioning include:

  • ability to regulate emotional distress
  • academic competence
  • positive self-esteem and self-efficacy
  • easygoing temperament and ability to elicit positive regard and warmth form caregivers
  • social competence
  • intelligence

What should you DO as a parent?

Depression is not something to be ashamed. It does not mean we are crazy either. Depression is an illness that makes it harder for us to recover from sadness.

Don’t stop your child from talking about things that are hard to hear. When your child is depressed may blame oneself often for no good reason, may say harsh things about him or her, may indicate that there is no hope for the future. When we hear things like this we tend to say things like “It is not true” or “You don’t really mean it” or “Stop saying this, don’t you see how what you say makes me sad?”. Give your child the right to have these feelings. Listen to what he or she has to say. Ask for more information. Children can easily get the idea that it’s not okay to feel depressed and start to hide their feelings rather than deal with them in a healthy way. By doing this it doesn’t mean you agree with what they say and you should indicate that, but you need to do this in a way that doesn’t block them from ever bringing up the issue with you.

Don’t minimize your child’s feelings. It may seem small to you, but what counts is how it feels to him.

Tell your child the truth about the problems. While too much information may not be helpful, not talking at all about a big problem that affects all the family may be damaging. We surely want to protect our children from pain, but kids are very good at picking up when something is wrong. By being honest with them we allow them to work through the pain.

Give your child time to grieve, even over the small things. A recent move may seem like a good thing to you, the parent, but may a big deal to a child who has never dealt with loss before. Opening the conversation yourself, indicating it is difficult for you too may be useful. Make sure you tell the child how you are coping yourself with the problem (talk with a friend, keep active, go for a walk, do something pleasurable or other examples).

Encourage your child to ask for help when they need it. Give them a list of people they may talk to such as yourself, a relative, a teacher, or counselor. Asking often if they need some help (in a tactful manner), model yourself how you are seeking help for your needs may be useful.

Make sure you are dealing with issues in a healthy way. Your child learns coping skills by watching you.

Learn the symptoms of depression and pay attention to your child’s symptoms. Talk with one of us about your observations. Although childhood suicide is rare, it does happen. Always take it very seriously if your child says he feels like he wants to die.

When should parents worry more about the risk for suicidal behavior?

  • onset of depression
  • worsening of depression
  • being suddenly cheerful after a period of depression
  • have signs of psychosis (hallucinations or bizarre thoughts)
  • unusual neglect of personal appearance
  • marked personality change
  • not tolerating praise or rewards
  • complain of being a bad person or feeling rotten inside
  • give verbal hints with statements such as: I won’t be a problem for you much longer, Nothing matters, It’s no use, and I won’t see you again

If you think your child is suicidal

Do not be afraid to ask if they are thinking of suicide. You are not giving them ideas that they haven’t already had.

Be calm and accepting of the child. If I get all agitated and distressed myself the child may feel it is not a good discussion to have and will stop communicating to you these very disturbing thoughts and feelings.

Listen attentively and encourage them to share what they are feeling. Allowing them to vent will reduce some of the pressure they feel inside.

Give them your full attention show that you take their feelings very seriously. A suicide attempt is never just attention seeking. Remember though to remain as calm and accepting of the child as possible.

Avoid the urge to explain how you see the issue. The child may get upset, stop talking with you. It is not that important how serious the problem appears to you, but how serious it feels to them. Instead, validate their feeling of being overwhelmed, offer support. If he or she needs your advice be tactful.

Ask if they have a plan and a means to carry out a suicide. Those who have a definite plan are in the most immediate danger.

Don’t leave them alone. If you must leave, contact someone you trust to take over.

Don’t hesitate to call 911 or get them to the closest Emergency Room if you feel they are in immediate danger.