Depression

Encyclopedia of Childhood and Adolescence by Boris Birmaher, M.D. and David Axelson, M.D. Department of Psychiatry University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic

Until recently, it was thought that children and adolescents could not suffer from clinical depression. It was assumed that children were not physically or psychologically mature enough to develop symptoms of depression and that adolescents with mood difficulties were simply going through "growing pains." However, several investigations have shown that if appropriately evaluated, children and adolescents do suffer from depression. We will refer to clinical depression that presents with severe symptoms as major depressive disorder (MDD) and depression that has moderate, chronic symptoms as dysthymic disorder (see below for specific criteria). Depression is relatively common; the prevalence (number of cases in one year) of MDD and dysthymic disorder combined is approximately 2% for children and 6% for adolescents.

Clinical features

Every child and adolescent can be occasionally and appropriately sad. However depression is more than just having a sad mood for a while. Children and adolescents with depression have a pervasive change in mood as well as a number of other clinical characteristics. There are four types of depression that child psychiatrists diagnose in children and adolescents: major depressive disorder (MDD), dysthymic disorder, adjustment disorder with depressed mood, and bipolar depression. Bipolar disorder (previously called manic-depressive illness) is another type of mood disorder consisting of periods of mania and depression. The diagnostic criteria and clinical presentation of the depressed phase of bipolar disorders is similar to that of MDD.

Major depressive disorder (MDD)

MDD is the most severe form of depression and has the most prominent clinical symptoms. Symptoms of MDD include:

1) persistent depressed or irritable mood most of the day (easily annoyed, angry, sad, anxious, hopeless; sometimes described as not having any emotion)

2) markedly diminished interest or pleasure in all or almost all activities (not able to enjoy activities that were previously fun, easily bored, sits around and does not do much)

3) significant weight loss or gain

4) sleep disturbance (trouble falling asleep, staying asleep, waking up too early, or sleeping more than usual)

5) psychomotor retardation (appearing to have slowed-down thinking and movements) or agitation (new onset of restless activity, pacing, unable to stay still)

6) fatigue or loss of energy (frequent complaints of feeling tired or having to push hard to do usual activities)

7) feelings of worthlessness or excessive guilt (very self-critical, blaming self for minor transgressions)

8) difficulty concentrating (distractible, unable to focus on challenging tasks, forgetful, indecisiveness)

9) thoughts of death or suicide , or attempting suicide

According to the American Psychiatric Association , to be diagnosed with MDD, the child or adolescent must have at least five of the above symptoms nearly every day for at least two weeks, and one of those symptoms must be either: (1) depressed or irritable mood; or (2) loss of interest and pleasure. These symptoms must represent a change from previous functioning and produce impairment in relationships with others or in performance of usual activities. The symptoms and change in mood cannot be attributed to abuse of drugs, use of medications, certain severe psychiatric illnesses, bereavement, or medical illness.

Overall, the clinical picture of childhood MDD parallels the symptoms of adult MDD, with some minor differences. In children, symptoms of anxiety (including phobias and trouble separating from caretakers), physical complaints, and behavioral problems seem to occur more frequently. Adolescents tend to have more sleep and appetite disturbances, psychosis (hallucinations or delusions), and impairment of functioning than younger children. In addition, the incidence and severity of suicide attempts increase after puberty.

Dysthymic disorder

Dysthymic disorder consists of a persistent, long-term change in mood which is generally less intense than in MDD. The associated symptoms of dysthymic disorder are not as severe as MDD. To be given a diagnosis of dysthymic disorder, the child or adolescent must have depressed mood or irritability on most days for most of the day over a period of one year, as well as at least two of the following symptoms: (1) change in appetite; (2) sleep disturbance; (3) low self-esteem; (4) poor concentration or difficulty making decisions; (5) decreased energy; or (6) feelings of hopelessness. In addition, they may have other symptoms, such as feelings of being unloved, anger, somatic complaints (such as stomach aches, nausea, or headaches), anxiety , and sometimes disobedience.

Adjustment disorder with depressed mood

Sometimes children and adolescents experience an excessive change in mood in response to a very stressful event or a series of stressful events. If they develop a persistently depressed mood (often with tearfulness and hopelessness) and impairment of functioning within three months of the stressor(s), but do not meet criteria for MDD or dysthymic disorder, then they would receive a diagnosis of an adjustment disorder with depressed mood. An adjustment disorder does not have the associated symptoms of MDD or dysthymic disorder. It is important to emphasize that MDD or dysthymic disorder may be precipitated by stressful events, so that if a child or adolescent has the appropriate symptoms, they should receive a diagnosis of MDD or dysthymic disorder. The prevalence, clinical course, and treatment of adjustment disorder with depressed mood have not been well studied in children and adolescents; a few studies indicate that it lasts for approximately six months and usually does not recur.

Presentation to outside observers

The diagnosis of depression can be difficult because the depressed and irritable mood often makes the child and adolescent less able and willing to share how they are feeling. Some of the symptoms of depression are difficult for others to observe because they are related to how the person is feeling inside. Parents and teachers may only notice that the depressed child or adolescent has become withdrawn, whiny, or moody. Little things make them angry or tearful, and they tend to view many situations as negative or overwhelming. They interact less with others and withdraw from favorite activities such as sports, social events, or extracurricular activities. Their school performance often declines, and the child may start to get into trouble at school or skip classes. However when clinically assessed, the depressed child or adolescent will often report sad mood, low energy, poor concentration, sleep or appetite changes, feelings of worthlessness or hopelessness, and thoughts of suicide. This underscores the necessity of gathering information from both outside observers and the child herself when assessing for depression.