Adolescent depression

• Alternative Names

  Depression - adolescents; Teenage depression

• Causes, incidence, and risk factors

  Depression can be a temporary response to many situations and stresses. In adolescents, depressed mood is common because of:

  • The normal process of maturing and the stress associated with it
  • The influence of sex hormones
  • Independence conflicts with parents

  It may also be a reaction to a disturbing event, such as:

  • The death of a friend or relative
  • A breakup with a boyfriend or girlfriend
  • Failure at school

  Adolescents who have low self-esteem, are highly self-critical, and who feel little sense of control over negative events are particularly at risk to become depressed when they experience stressful events.

  Adolescent girls are twice as likely as boys to experience depression.

  Risk factors include:

  • Child abuse - both physical and sexual
  • Chronic illness
  • Family history of depression
  • Poor social skills
  • Stressful life events, particularly loss of a parent to death or divorce
  • Unstable caregiving

  Depression is also associated with eating disorders, particularly bulimia.

• Symptoms
  • Acting-out behavior (missing curfews, unusual defiance)
  • Appetite changes (usually a loss of appetite but sometimes an increase)
  • Criminal behavior (such as shoplifting)
  • Depressed or irritable mood
  • Difficulty concentrating
  • Difficulty making decisions
  • Episodes of memory loss
  • Excessive sleeping or daytime sleepiness
  • Excessively irresponsible behavior pattern
  • Excessive or inappropriate feelings of guilt
  • Failing relations with family and friends
  • Faltering school performance
  • Fatigue
  • Feelings of worthlessness, sadness, or self-hatred
  • Loss of interest in activities
  • Persistent difficulty falling asleep or staying asleep (insomnia)
  • Plans to commit suicide or actual suicide attempt
  • Preoccupation with self
  • Reduced pleasure in daily activities
  • Substance abuse
  • Temper (agitation)
  • Thoughts about suicide or obsessive fears or worries about death
  • Weight change (unintentional weight loss or gain)

  If these symptoms last for at least 2 weeks and cause significant distress or difficulty functioning, get treatment.

• Signs and tests

  True depression in teens is often difficult to diagnose, because normal adolescents have both up and down moods. These moods may alternate over a period of hours or days.

  The health care provider will perform a physical examination and order blood tests to rule out medical causes for the symptoms. The doctor will also evaluate for signs of substance abuse. Heavy drinking, frequent marijuana (pot) smoking, and other drug use can be caused by, or occur because of depression.

  A psychiatric evaluation will also be done to document the teen's history of sadness, irritability, and loss of interest and pleasure in normal activities. The doctor will look for signs of potentially coexisting psychiatric disorders such as anxiety, mania, or schizophrenia. A careful assessement will help determine suicidal/homicidal risks -- that is, if the teen is a danger to him or herself or others.

  Information from family members or school personnel can often help identify depression in teenagers.

• Treatment

  Treatment options for adolescents with depression include supportive care from a medical provider, psychotherapy, and antidepressant medications. It is important that treatment be customized to the adolescent and the severity of depression symptoms. Families often participate in the treatment of adolescent depression.

  MEDICATION

  The first medication considered is usually a type of antidepressant called selective serotonin reuptake inhibitors (SSRI). NOTE: SSRIs carry a warning that they may increase the risk of suicidal thoughts and actions in children and adolescents. Teens and families should be alert for sudden changes or increased suicidal thoughts. Talk to your doctor about the benefits and risks of this type of medicine.

  Not all antidepressants are approved for use in children and teens. For example, tricyclics are not approved for use in teens.

  THERAPY

  Family therapy may be helpful if family conflict is contributing to the depression. Support from family or teachers may also be needed to help with school problems. Occasionally, hospitalization in a psychiatric unit may be required for individuals with severe depression, or those who are suicide risks.

  Because of the behavior problems that often occur with adolescent depression, many parents are tempted to send their child to a "boot camp," "wilderness program," or "emotional growth school." These programs often use non-medical staff, confrontational therapies, and harsh punishments. There is no scientific evidence to support such programs. In fact, there is a growing body of research suggesting they can actually harm sensitive teens with depression.

  Depressed teens who act out may also become involved with the criminal justice system. Parents are often advised not to intervene, but to "let them experience consequences." This can harm teens by exposing them to more deviant peers and reducing their educational opportunities. A better solution is to get the best possible legal advice and search for treatment on your own. This gives parents more control over treatment techniques and options.

  Though a large percentage of teens in the criminal justice system have mental disorders such as depression, few juvenile prisons, "boot camps," or other "alternative to prison" programs provide adequate treatment.

• Expectations (prognosis)

  Depressive episodes usually respond to treatment. Early and appropriate treatment of depression in adolescence may prevent further episodes. However, about half of seriously depressed teens are likely to have continued problems with depression as adults.

• Complications
  • Drug, alcohol, and tobacco abuse
  • Effects on school performance and interpersonal relationships
  • Other psychiatric problems, such as anxiety disorders
  • Teenage suicide
  • Violence and reckless behavior

  Adolescents with additional psychiatric problems usually require longer and more intensive treatment.

• Calling your health care provider

  Call your health care provider if you notice one or more suicide warning signs:

  • Giving most cherished possessions to others
  • Moodiness
  • Personality change
  • Threat of suicide
  • Withdrawal, urge to be alone, isolation

  NEVER IGNORE A SUICIDE THREAT OR ATTEMPT!

• Prevention

  Periods of depressed mood are common in most adolescents. However, supportive relationships and healthy coping skills can help prevent these periods from leading to more severe depressive symptoms. Open communication with your teen can help identify depression earlier.

  Counseling may help teens deal with periods of low mood. Cognitive behavioral therapy, which teaches depressed people ways of fighting negative thoughts, is the most effective non-medication treatment for depression. Ensure that the counsellors or psychologists you work with are well trained in this method.

  For adolescents with a strong family history of depression or multiple risk factors, episodes of depression may not be preventable. For these teens, early identification and prompt and appropriate treatment of depression may prevent or postpone further episodes.

• References

  Agerter DC, Rasmussen NH, Sutor B. Depression. In: Rakel RE, ed. Textbook of Family Medicine. 7th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 58.

  Borrillo Cm, Boris NW. Mood disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 25.

  Boris NW, Dalton R. Suicide and attempted suicide. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 26.

  Zuckerbrot RA, Cheung AH, Jenson PS, Stein REK. Identification, assessment, and initial management guidelines for adolescent depression in primary care. Pediatrics. 2007;120:e1299-e1312.

  Cheung AH, Zuckerbrot RA, Jenson PS, Ghalib K. Treatment and ongoing management guidelines for adolescent depression in primary care. Pediatrics. 2007;120:e1313-e1326.

Review Date: 1/20/2009

Reviewed By: Paul Ballas, DO, Department of Psychiatry, Thomas Jefferson University Hospital, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.