Depression

Encyclopedia of Childhood and Adolescence, Apr 06, 2001 by Boris Birmaher, M.D. and David Axelson, M.D. Department of Psychiatry University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic

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 Parents and teachers may only notice that the depressed child or adolescent has become withdrawn, whiny, or moody.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.

Forty to 70% of children and adolescents with clinical depression also have other coexisting psychiatric diagnoses, such as disruptive behavior disorders (conduct disorder , oppositional defiant disorder, and attention deficit/hyperactivity disorder ), anxiety disorders, abuse of drugs and/or alcohol, and eating disorders (bulimia nervosa and anorexia nervosa ). Identification and treatment of the coexisting psychiatric disorders may be important for the overall treatment of the depression.

MDD episodes tend to last approximately 7-9 months, and about 90% of the major depressive episodes end by 1.5-2 years after the onset. Between 6 and 10% of MDD episodes become chronic. Depression is a recurrent disorder; a child or adolescent experiencing a first episode of MDD has a 40% probability of developing another depressive episode within the next two years and 70% chance within the next five years.

Follow-up studies of depressed adolescents have found that 20-40% of adolescents with MDD are at risk to develop bipolar disorder within a five year period after the onset of the depression. Characteristics associated with the conversion from MDD to bipolar disorder include the presence of psychomotor retardation and psychosis during the depression, family history of bipolar disorder or strong family history for mood disorders, and the development of agitation, high energy, or euphoria when taking antidepressant medications.

Furthermore, over a period of five years, approximately 70% of the children and adolescents with dysthymic disorders will develop an episode of MDD. Once these children have developed MDD, the course of their mood disorders follows the natural course of MDD. Therefore it may be very important to identify and treat childhood dysthymic disorder early.

The most severe complications of depression are suicidal ideation and suicide attempts. The adolescent suicide rate has quadrupled since 1950 (from 2.5 to 11.2 per 100,000), and currently represents 12% of the total mortality in this age group. Beyond depression, predisposing factors for suicidality include the existence of anxiety, disruptive, bipolar and personality disorders, and substance abuse. In addition, family history of depression or bipolar disorder, family history of suicidal behavior, exposure to family violence, impulsivity, and availability of methods (e.g., firearms at home) have been associated with an increased risk for suicide.