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How frequent is depression in children and adolescents?

  • At any point in time 1–2% of the children and up to 3–8% of adolescents suffer from one form of depression.
  • By the end of adolescence around 20% (one in five) of all people had an episode of 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. About 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
    • The child has a history of being neglected or abused
    • One or both parents are depressed or anxious
    • Somebody close passed away like a sibling, parent, or a close friend.
    • Problems in the family
      • parent has legal problems
      • parent is abusing alcohol or drugs
      • parent-parent conflict
      • parent-child conflict

 

 

Symptoms of Depression common for all ages (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

In addition to (or instead of) the symptoms listed above, children and adolescents may display:

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

Difficulties with relationships

Fear of death

Outbursts of shouting, complaining, unexplained irritability, or crying

Talk of or attempts to run away from home

Reckless behavior

Alcohol or substance abuse

Types of Depression

There are several diagnoses for 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

 

Often, 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

Oppositional Defiant and Conduct disorder – behavioral or antisocial 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 depressive symptoms is more likely if…

  • The child has Dysthymic disorder
  • The child has an additional psychiatric disorder (for example anxiety disorder or substance abuse)
  • The depression was more severe to start with
  • The child has (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:
    1. if there is family history of bipolar disorder
    2. if the child becomes activated, agitated when given an antidepressant
    3. if he or she has psychotic symptoms like hallucinations and delusions.
    4. 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 – does not get tired

Agitation – an exaggerated form of excitement

Increased goal-directed activity - making plans, overly dedicated to certain projects, apparently having increased productivity

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 for 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 (and are recommended) to try psychotherapy before considering medications. Psychotherapy can be extremely 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 adaptive 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 behavior. 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 Obsessive Compulsive Disorder in children. This does not necessarily mean that other drugs are less safe. It simply means that those drugs have not been tested as much 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, or therapy combined with medications may be recommended. Generally, starting an antidepressant without a good psychotherapy attempt is not recommended. An antidepressant may help your child begin to feel better. But, the negative thought patterns which lead to depression may still remain and may increase the risk for future relapse. Therapy will help the child alter these thought patterns and better cope with the stressors that contribute to depression.

 

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