Major Depression in Children and Adolescents

INTRODUCTION

Two decades ago, clinical depression was thought to be an illness exclusive to adults. Now, there is a consensus that clinical depression occurs in children and adolescents, is often recurrent leading to impairment in work, social and family life in adulthood.

Forty percent of adolescents report an occasional depressed mood, however, 2% of children and 4 to 8% of adolescents will develop clinical depression. There are no gender differences in childhood depression. Gender differences emerge between the ages of thirteen to fifteen with the male to female ratio becoming one to two. Episodes of depression persist on average eight to nine months and 90% remit within one to two years. It is important that those who remit continue to be monitored for recurrence. There is no gender difference in course.

Recurrence rates are high with new episodes reported in up to 72% of those followed for three to eight years. Adult depression is predicted if there is a history of child and adolescent depression, however most adult onset depression is not preceded by adolescent depression. Following recovery, subclinical symptoms of depression often continue, interpersonal relationships may be impaired and global functioning compromised.

CLINICAL PRESENTATION

Symptoms of depression in children and adolescents are similar to that found in adults, however presentation may be different (see Table 1). In addition to major depression, psychotic, melancholic, seasonal and bipolar subtypes are found in these age groups. Up to 20% with major depression in younger age groups will develop a bipolar illness, the likelihood enhanced if there is a family history of bipolar disorder.

Children experience more somatic symptoms than adults, stomachache and headache being the most common. Sleep and appetite disturbances are more common in adolescence, as is the sense of hopelessness, irritability and anger. Where guilt, self - reproach, restlessness, immobility and weight fluctuations occur, a more severe depression is predicted.

Suicide attempts and completed suicide are more common in adolescents than in children. The most common age of adolescent suicide is between the ages of fifteen to sixteen. Helpful in assessing suicide risk of your child is asking the question, "Have you recently, or in the past, felt so bad that you felt like killing yourself?" If the answer is yes, ask how frequent the thoughts were and how they planned to suicide. Most appreciate the asking of these questions and are honest in reply. Potential risk factors for adolescent suicide are listed in Table 2.

DEPRESSION DOES NOT OCCUR ALONE

Depression commonly occurs with other psychiatric illnesses. When this does occur, it increases the risk of recurrence, lengthens the course, enhances severity, dictates a poor treatment response and suicide is more frequent. Where there is dysthymia, a chronic low - grade depression that may last for years and is less disabling than major depression, the impairment is greater than if depression occurs alone. Table 3 lists common co - occurring illnesses in child and adolescent depression. The anxiety disorders affect 40%, conduct disorder 30% and attention deficit hyperactive disorder (ADHD) 24%. Onset of these disorders usually precedes the depression. For example in 85% of those with a co - occurring anxiety disorder, onset occurs prior to depression. That these disorders precede the onset of depression has raised the question, “will treatment of these disorders inhibit the onset of depression?” To date, the evidence is unclear. 20% to 30% develop drug abuse following the onset of depression; continued abuse maintains and worsens symptoms.

RISK FACTORS FOR EARLY ONSET DEPRESSION

Today, major depression is conceptualised as a familial disorder mediated via genetic and environmental mechanisms specific to the individual. Thus, onset is more likely if there is a family history of depression, the risk enhanced if the mother is diagnosed with major depression rather than the father. There is a thirteen - fold increase in risk if a parent has also experienced early onset. Other risk factors include early parental death, separation from parents, sexual abuse, physical illness, low socio - economic status, poor academic achievement and persistent depressive cognitions.

Click here for Treatments