Provided by the National Institute of Mental Health
Depressive disorders, which include major
depressive disorder (unipolar depression), dysthymic disorder (chronic, mild
depression), and bipolar disorder (manic-depression), 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 resolved; in adolescents there is also an increased risk
for substance abuse and suicidal behavior.1,2,3 Unfortunately, these disorders
often go unrecognized by families and physicians alike. Signs of depressive
disorders in young people often are 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 of depressive disorders are critical to
healthy emotional, social, and behavioral development.
Although the scientific literature on treatment of children and adolescents with
depression is far less extensive than that concerning adults, a number of
studies—mostly conducted in the last four to five years—have confirmed the
short-term efficacy and safety of treatments for depression in youth. Larger
treatment trials are needed to determine which treatments work best for which
youngsters, and studies are also needed, however, 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 physicians can obtain more information.
Scope of the Problem
A number of epidemiological studies have reported that up to 2.5 percent of
children and up to 8.3 percent of adolescents in the U.S. suffer from
depression.4 An NIMH-sponsored study of 9- to 17-year-olds estimates that the
prevalence of any depression is more than 6 percent in a 6-month period, with
4.9 percent having major depression.5 In addition, research indicates that
depression onset is occurring earlier in life today than in past decades.6 A
recently published longitudinal prospective study found that early-onset
depression often persists, recurs, and continues into adulthood, and indicates
that depression in youth may also predict more severe illness in adult life.3
Depression in young people often co-occurs with other mental disorders, most
commonly anxiety, disruptive behavior, or substance abuse disorders, 7 and with
physical illnesses, such as diabetes.8
Suicide. Depression in children and adolescents is associated with an increased
risk of suicidal behaviors.3,9 This risk may rise, particularly among adolescent
boys, if the depression is accompanied by conduct disorder and alcohol or other
substance abuse.10 In 1997, suicide was the third leading cause of death in 10-
to 24-year-olds.11 NIMH-supported researchers found that among 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 firearms 12 and medications—may hold the greatest suicide
prevention value.
Clinical Characteristics
The diagnostic criteria and key defining features of major depressive disorder
in children and adolescents are the same as they are for adults. However,
recognition and diagnosis of the disorder may be more difficult in youth for
several reasons. The way symptoms are expressed varies with the developmental
stage of the youngster.1,2 In addition, children and young adolescents with
depression may have difficulty in properly identifying and describing their
internal emotional or mood states. For example, instead of communicating how bad
they feel, they may act out and be irritable toward others, which may be
interpreted simply as misbehavior or disobedience. Research has found that
parents are even less likely to identify major depression in their adolescents
than are the adolescents themselves.13
Symptoms of Major Depressive Disorder Common to Adults, Children, and
Adolescents14
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 major depression is indicated.
Signs That May Be Associated with Depression 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
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, 15 episodes are likely to recur.16 In addition,
youth with dysthymic disorder are at risk for developing major depression.17
Prompt identification and treatment of depression can reduce its duration and
severity and associated functional impairment.
Screening
There are several tools that are useful for screening children and adolescents
for possible depression. They include the Children's Depression Inventory (CDI)
18 for ages 7 to 17; and, for adolescents, the Beck Depression Inventory (BDI)
19 and the Center for Epidemiologic Studies Depression (CES-D) Scale.20 When a
youngster screens positive on any of these instruments, a comprehensive
diagnostic evaluation by a mental health professional is warranted. The
evaluation should include interviews with the youth, parents, and when possible,
other informants such as teachers and social services personnel.
Risk Factors
In childhood, boys and girls appear to be at equal risk for depressive
disorders; but during adolescence, girls are twice as likely as boys to develop
depression.4 Children who develop major depression are more likely to have a
family history of the disorder, often a parent who experienced depression at an
early age, than patients with adolescent- or adult-onset depression.21
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.
Other risk factors include:
Stress 22
Cigarette smoking 22
A loss of a parent or loved one 23
Break-up of a romantic relationship 24
Attentional, conduct or learning disorders 25
Chronic illnesses, such as diabetes 8
Abuse or neglect 26
Other trauma, including natural disasters 27
Treatment
Treatment for depressive disorders in children and adolescents often involves
short-term psychotherapy, medication, or the combination, and targeted
interventions involving the home or school environment. There remains, however,
a pressing need for additional research on the effectiveness of psychosocial and
pharmacological treatments for depression in youth. While data from adults
indicate the need for maintenance treatment after episode recovery in order to
prevent recurrences, the value of such treatment in children and adolescents has
yet to be determined through research.
Psychotherapy. Recent research shows that certain types of short-term
psychotherapy, particularly cognitive-behavioral therapy (CBT), can help relieve
depression in children and adolescents.1,28,29 CBT is based on the premise that
people with depression 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 that compared different
types of psychotherapy for major depression in adolescents found that CBT led to
remission in nearly 65 percent of cases, a higher rate than either supportive
therapy or family therapy. CBT also resulted in a more rapid treatment
response.30
Another specific psychotherapy, interpersonal therapy (IPT), focuses on working
through disturbed personal relationships that may contribute to depression. IPT
has not been well investigated in youth with depression; however, one controlled
study found that IPT led to greater improvement than clinical contact alone.31
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.1
Medication. Research clearly demonstrates that antidepressant medications,
especially when combined with psychotherapy, can be very effective treatments
for depressive disorders in adults.32 Using medication to treat mental illness
in children and adolescents, however, has caused controversy. Many doctors have
been understandably reluctant to treat young people with psychotropic
medications because, until fairly recently, little evidence was available about
the safety and efficacy of these drugs in youth.
In the last few years, however, researchers have been able to conduct
randomized, placebo-controlled studies with children and adolescents. Some of
the newer antidepressant medications, specifically the selective serotonin
reuptake inhibitors (SSRIs), have been shown to be safe and efficacious 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 two controlled studies showing efficacy of fluoxetine and paroxetine,
respectively.33,34 It is important to note that available studies do not support
the efficacy of tricyclic antidepressants (TCAs) for depression in youth.35,36
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 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 6 weeks or longer.1
NIMH has initiated a large-scale, controlled clinical trial at 10 sites across
the U.S. to compare the long-term effectiveness of fluoxetine, CBT, and the
combination of these interventions for treatment of depression in adolescents.
More information about this trial, called the Treatment of Adolescents with
Depression Study (TADS), and others can be found through the Clinical Trials
page of the NIMH web site at http://www.nimh.nih.gov/studies/index.cfm.
Talking With Parents
It is very important for parents to understand their child's depression and the
treatments that may be prescribed. Physicians can help by talking with parents
about their questions or concerns, reinforcing that depression in youth is not
uncommon, and reassuring them that appropriate treatment with psychotherapy,
medication, or the combination can lead to improved functioning at school, with
peers, and at home with family. In addition, referring the youth and family to a
mental health professional and to the information resources listed at the back
of this publication can help to enhance recovery.
Other Types of Depression in Children and Adolescents
Bipolar Disorder
Although rare in young children, bipolar disorder—also known as manic-depressive
illness—can appear in both children and adolescents.37 Bipolar disorder, which
involves unusual shifts in mood, energy, and functioning, may begin with either
manic, depressive, or mixed manic and depressive symptoms. It is more likely to
affect the children of parents who have the disorder. Twenty to forty percent of
adolescents with major depression develop bipolar disorder within 5 years after
depression onset.4
Existing evidence indicates that bipolar disorder beginning in childhood or
early adolescence may be a different, possibly more severe form of the illness
than older adolescent- and adult-onset bipolar disorder.38 When the illness
begins before or soon after puberty, it is often characterized by a continuous,
rapid-cycling, irritable, and mixed symptom state that may co-occur with
disruptive behavior disorders, particularly attention deficit hyperactivity
disorder (ADHD) or conduct disorder (CD), or may have features of these
disorders as initial symptoms. In contrast, later adolescent- or adult-onset
bipolar disorder tends to begin suddenly, often with a classic manic episode,
and to have a more episodic pattern with relatively stable periods between
episodes. There is also less co-occurring ADHD or CD among those with later
onset illness.
Bipolar Disorder: Manic Symptoms14,37
Severe changes in mood—either extremely irritable or overly silly and elated
Overly-inflated self-esteem; grandiosity
Increased energy
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
Hypersexuality—increased sexual thoughts, feelings, or behaviors; use of
explicit sexual language
Increased goal-directed activity or physical agitation
Disregard of risk—excessive involvement in risky behaviors or activities
A child or adolescent who appears to be depressed and exhibits ADHD-like
symptoms that are very severe, with excessive temper outbursts and mood changes,
should be evaluated by a psychiatrist or psychologist with experience in bipolar
disorder, particularly if there is a family history of the illness. This
evaluation is especially important since psychostimulant medications, 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.38
The essential treatment of bipolar disorder in adults involves the use of
appropriate doses of mood stabilizing medications, typically lithium and/or
valproate, which are often very effective for controlling mania and preventing
recurrences of manic and depressive episodes. Treatment of children and
adolescents diagnosed with bipolar disorder is based mainly on experience with
adults, since as yet there is very limited data on the safety and efficacy of
mood stabilizing medications in youth. Researchers currently are evaluating both
pharmacological and psychosocial interventions for bipolar disorder in young
people.
Bipolar Disorder: A Warning About Antidepressants and Psychostimulants
Using antidepressant medication to treat depression in a person who has bipolar
disorder may induce manic symptoms if it is taken without a mood stabilizer,
such as lithium or valproate.37 In addition, using psychostimulant medications
to treat ADHD or ADHD-like symptoms in a child or adolescent with bipolar
disorder may worsen manic symptoms. While it can be hard to determine which
young patients will become manic, there is a greater likelihood among children
and adolescents who have a family history of bipolar disorder. If manic symptoms
develop or markedly worsen during antidepressant or stimulant use, a child
psychiatrist should be consulted, and treatment for bipolar disorder should be
considered. Physicians should be aware of the signs and symptoms of mania so
that they can educate families on how to recognize these and report them
immediately.
Valproate Use
According to studies conducted in Finland in patients with epilepsy, valproate
may increase testosterone levels in teenage girls and produce polycystic ovary
syndrome in women who began taking the medication before age 20.39 Increased
testosterone can lead to polycystic ovary syndrome with irregular or absent
menses, obesity, and abnormal growth of hair. Therefore, young female patients
prescribed valproate should be monitored carefully.
Dysthymic disorder (or dysthymia)
This less severe yet typically more chronic form of depression is diagnosed when
depressed mood persists for at least 1 year in children or adolescents and is
accompanied by at least two other symptoms of major depression.14 Dysthymia is
associated with an increased risk for developing major depressive disorder,
bipolar disorder, and substance abuse.4,17 Treatment of dysthmia may prevent the
deterioration to more severe illness.1 If dysthymia is suspected in a young
patient, referral to a mental health specialist is indicated for a comprehensive
diagnostic evaluation and appropriate treatment.
Information Resources
Please visit the following links for information on organizations that focus on
depression and child and adolescent mental health.
All material in this fact sheet is in the public domain and may be copied or
reproduced without permission from the Institute. Citation of the source is
appreciated.
References
1Birmaher B, Brent DA, Benson RS. Summary of the practice parameters for the
assessment and treatment of children and adolescents with depressive disorders.
American Academy of Child and Adolescent Psychiatry. Journal of the American
Academy of Child and Adolescent Psychiatry, 1998; 37(11): 1234-8. See also
www.aacap.org/clinical/Depres~1.htm.
2Ryan ND, Puig-Antich J, Ambrosini P, et al. The clinical picture of major
depression in children and adolescents. Archives of General Psychiatry, 1987;
44: 854-61.
3Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grown up.
Journal of the American Medical Association, 1999; 281:1701-13.
4Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression:
a review of the past 10 years. Part I. Journal of the American Academy of Child
and Adolescent Psychiatry, 1996; 35(11): 1427-39.
5Shaffer D, Fisher P, Dulkan MK, 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. Journal of the American Academy of
Child and Adolescent Psychiatry, 1996; 35(7): 865-77.
6Klerman GL, Weissman MM. Increasing rates of depression. Journal of the
American Medical Association, 1989; 261: 2229-35.
7Angold A, Costello EJ. Depressive comorbidity in children and adolescents:
empirical, theoretical, and methodological issues. American Journal of
Psychiatry, 1993; 150(12): 1779-91.
8Kovacs M. Psychiatric disorders in youths with IDDM: rates and risk factors.
Diabetes Care, 1997; 20(1): 36-44.
9Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and
adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339-48.
10Shaffer D, Craft L. Methods of adolescent suicide prevention. Journal of
Clinical Psychiatry, 1999; 60(Suppl 2): 70-4; discussion 75-6, 113-6.
11Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital
Statistics Report. DHHS Publication No. (PHS) 99-1120. Hyattsville: National
Center for Health Statistics, 1999; 47(19).
12Brent DA, Perper JA, Allman CJ, et al. The presence and accessibility of
firearms in the homes of adolescent suicides. A case-control study. Journal of
the American Medical Association, 1991; 266(21): 2989-95.
13Fleming JE, Offord DR. Epidemiology of childhood depressive disorders: a
critical review. Journal of the American Academy of Child and Adolescent
Psychiatry, 1990; 29(4): 571-80.
14American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Press,
1994.
15Kovacs M, Feinberg TL, Crouse-Novak MA, et al. Depressive disorders in
childhood. I. A longitudinal prospective study of characteristics and recovery.
Archives of General Psychiatry, 1984; 41(3): 229-37.
16Lewinsohn PM, Clarke GN, Seeley JR, et al. Major depression in community
adolescents: age at onset, episode duration, and time to recurrence. Journal of
the American Academy of Child and Adolescent Psychiatry, 1994; 33(6): 809-18.
17Klein DN, Schwartz JE, Rose S, et al. Five-year course and outcome of
dysthymic disorder: a prospective, naturalistic follow-up study. American
Journal of Psychiatry, 2000; 157(6): 931-9.
18Children's Depression Inventory. Developed by Kovacs M. Available from
Multi-Health Systems (MHS, Inc.), 65 Overlea Blvd., Suite 10,Toronto, Ontario
M4H1P1 Canada; phone: 800-456-3003.
19Beck Depression Inventory. Developed by Beck A. Available from Psychological
Corporation, 555 Academic Court, San Antonio, TX 78204; phone: 210-299-1061.
20Center for Epidemiologic Studies Depression Scale. Developed by NIMH.
Available from NIMH, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD
20892-9663; phone: 301-443-4513.
21Harrington R, Rutter M, Weissman MM, et al. Psychiatric disorders in the
relatives of depressed probands. I. Comparison of prepubertal, adolescent and
early adult onset cases. Journal of Affective Disorders, 1997; 42(1): 9-22.
22Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older
adolescents: prevalence, risk factors, and clinical implications. Clinical
Psychology Review, 1998; 18(7): 765-94.
23Wells VE, Deykin EY, Klerman GL. Risk factors for depression in adolescence.
Psychiatric Development, 1985; 3(1):83-108.
24Monroe SM, Rohde P, Seeley JR, et al. Life events and depression in
adolescence: relationship loss as a prospective risk factor for first onset of
major depressive disorder. Journal of Abnormal Psychology, 1999; 108(4): 606-14.
25Spencer T, Biederman J, Wilens T. Attention-deficit/hyperactivity disorder and
comorbidity. Pediatric Clinics of North America, 1999; 46(5): 915-27, vii.
26Brown J, Cohen P, Johnson JG, et al. Childhood abuse and neglect: specificity
of effects on adolescent and young adult depression and suicidality. Journal of
the American Academy of Child and Adolescent Psychiatry, 1999; 38(12): 1490-6.
27Krug EG, Kresnow M, Peddicord JP, et al. Suicide after natural disasters. New
England Journal of Medicine, 1998; 338(6): 373-8.
28Jayson D, Wood A, Kroll L, et al. Which depressed patients respond to
cognitive-behavioral treatment? Journal of the American Academy of Child and
Adolescent Psychiatry, 1998; 37(1): 35-9.
29Reinecke MA, Ryan NE, DuBois DL. Cognitive-behavioral therapy of depression
and depressive symptoms during adolescence: a review and meta-analysis. Journal
of the American Academy of Child and Adolescent Psychiatry, 1998; 37(1): 26-34.
30Brent DA, Holder D, Kolko D, et al. A clinical psychotherapy trial for
adolescent depression comparing cognitive, family, and supportive therapy.
Archives of General Psychiatry, 1997; 54(9): 877-85.
31Mufson L, Weissman MM, Moreau D, et al. Efficacy of interpersonal
psychotherapy for depressed adolescents. Archives of General Psychiatry, 1999;
56(6): 573-9.
32Depression Guideline Panel. Clinical practice guideline, number 5. Depression
in primary care: volume 2. Treatment of major depression. AHCPR Publication No.
93-0551. Rockville: U.S. Department of Health and Human Services, Agency for
Health Care Policy and Research, 1993.
33Emslie GJ, Rush AJ, Weinberg WA, et al. A double-blind, randomized,
placebo-controlled trial of fluoxetine in children and adolescents with
depression. Archives of General Psychiatry, 1997; 54(11): 1031-7.
34Keller M. Paroxetine and imipramine in the treatment of adolescent depression.
Presented at the 151st Annual Meeting of the American Psychiatric Association,
Toronto, June 1998.
35Geller B, Cooper TB, Graham DL, et al. Pharmacokinetically designed
double-blind placebo-controlled study of nortriptyline in 6- to 12-year-olds
with major depressive disorder. Journal of the American Academy of Child and
Adolescent Psychiatry, 1992; 31(1): 34-44.
36Geller B, Reising D, Leonard HL, et al. Critical review of tricyclic
antidepressant use in children and adolescents. Journal of the American Academy
of Child and Adolescent Psychiatry, 1999; 38(5): 513-6.
37McClellan J, Werry J. Practice parameters for the assessment and treatment of
children and adolescents with bipolar disorder. American Academy of Child and
Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent
Psychiatry, 1997; 36(Suppl 10): 157S-76S.
38Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past
10 years. Journal of the American Academy of Child and Adolescent Psychiatry,
1997; 36(9): 1168-76.
39Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism
during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999;
45(4): 444-50.
NIH Publication No. 00-4744
Printed 2000