In the 2000 Youth Risk Behavior Surveillance report, thirty-two percent of Boston high school students felt sad or hopeless. In addition, twenty percent seriously considered attempting suicide, sixteen percent made a suicide plan, eight percent attempted suicide and about four percent required medical attention for their suicide attempt.
Depression is a feeling of sadness and a loss of interest in the activities of daily life that is common in adolescence but can be very serious. Freud spoke of “everyday misery,” and it is important to note that feeling sadness or depressed occurs in the course of everyone’s life. These feelings and how an individual deals with them may offer an opportunity for personal growth. Feelings of sadness or irritability are a normal part of life especially in response to perceived failure or disappointment. In addition, changes in mood or loss of interest in what were fun activities do not represent psychiatric disease. However, depression that does not resolve, also known as clinical depression, can be a very serious illness that could be a threat to an adolescent’s well being. It is a treatable condition both with medications and by counseling and therapy.
It is important to note that adolescent depression can have very different characteristics from adult depression. Given that adolescents go through many physical and emotional changes, they are particularly susceptible to feelings of depression. When feelings of depression do not improve, an adolescent is at risk to be unable to successfully engage in the activities of their life. If severe, adolescent depression can lead to thoughts of suicide and self-harm that must be taken seriously and addressed.
Who is likely to develop depression?
Adolescents are at a greater risk for depression since they struggle within their peer groups, families and communities over issues including identity, self-esteem, growth and development. Teens need to sort through many different issues and with these tasks, there are changes in mood, attitudes and behaviors. With these factors as well as the hormonal changes in adolescence, teens are at increased risk for depression.
In the adolescent population it is estimated that fifteen to twenty percent of all adolescents will have at least one episode of clinical depression. Teenage girls are at twice the risk of developing depression as teenage boys. In addition adolescents seem to be more at risk for developing depression than they were in the past.
Genetic, biologic and environmental factors play a role in the cause of depression. A prior personal history or family history of depression can be an important risk factor for adolescent depression. Researchers have identified a defect in the gene called SERT, which has a regulatory role over the neurotransmitter serotonin. Teens with this defect have a higher risk for depression. And adolescents who have problems interacting with peer groups or with family members as well as academic difficulties can be susceptible to depression. Finally adolescents with a chronic illness are more likely to suffer from depression.
Most episodes of clinical depression in adolescents last seven to nine months. However, relapse into depression is common with forty percent having another depressive episode in two years and seventy percent in five years. Experts feel that the highest risk for depression is among girls after puberty.
What are the symptoms of depression?
Many signs typically associated with depression are also a part of everyday life. A key difference is that these changes in mood do not improve and cause an individual significant stress that interferes with his or her day-to-day activities.
In adolescents common signs include problems at school or with relationships including their parents and peers. There may be a loss of initiative and interest in previously important activities. Teens may be irritable or have a change in their appetites and weight. Many adolescents with depression have changes in their sleep habits including an increased need for sleep or difficulty remaining asleep. Another important sign is that depressed adolescents often complain of medical problems such as headache, stomachache or fatigue in the absence of a medical cause. Adolescents with depression are also at much greater risk for behaviors such as smoking, alcohol abuse, substance abuse, suicide attempts, and promiscuity.
If depression persists for an extended period of time some signs may become more prominent. An adolescent may stop participating in social activities or have greater difficulties interacting with peers. A teen may also show signs of poor self-esteem or may begin to have significant difficulties at school including academic failure.
Also of importance is that forty to seventy percent of depressed children have other psychiatric or behavioral disorders. Most frequently these are substance abuse, anxiety disorders, and behavior disorders such as attention deficit hyperactivity disorder (ADHD). There is also an increased chance of having eating disorders and learning problems in depressed adolescents.
There are several categories of depressive disorders including major depressive disorder, dysthymic disorder, and seasonal affective disorder. Major depressive disorder is diagnosed when at least five of the following signs are present for more than two weeks associated with a depressed mood, irritability or boredom:
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Change in sleep habits, difficulty falling asleep, staying asleep or awakening too early
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Loss of interest in activities or academics
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Feelings of guilt or worthlessness
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Lack of energy
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Problems with concentration on academics or other activities
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Feelings of lethargy or agitation
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Suicidal thoughts, intentions or acts
Dysthymic disorder is a less severe form of depression that often lasts longer than major depressive disorder. Adolescents with this condition have a depressed or irritable mood for at least one year, plus at least two of the following:
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Appetite disturbance
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Sleep disturbance
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Fatigue
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Low self-esteem
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Poor concentration
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Difficulty making decisions
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Feelings of hopelessness
Seasonal affective disorder (SAD) is characterized by fatigue, a tendency to overeat, especially carbohydrates and excessive sleepiness during the winter months when the amounts of sunlight are diminished. This occurs annually in affected teens, and the symptoms will begin in the fall or winter and remit in the spring and summer. Teens in northern climates are at more risk for SAD. More females are affected with SAD than males. It should be noted that many individuals without SAD have the “blues” in the winter.
How is depression evaluated?
It is very difficult to evaluate a teenager for depression since the adolescent’s symptoms may be vague or not specific for depression. Transient changes in mood, attitudes and behaviors are also normal during adolescence. Of concern is that seventy to eighty percent of teenagers with clinical depression do not receive treatment.
In order to diagnose depression, a thorough clinical interview should be performed and supplemented by information from parents, teachers, and other family members. Depression is probably best evaluated by a mental health specialist including a psychiatrist, psychologist, social worker or psychiatric nurse clinician although there is ongoing work at the Massachusetts General Hospital Division of Adolescent Medicine and the Department of Psychiatry to teach pediatricians to diagnose and manage adolescent depression. It is very important when discussing depression with an adolescent that questions be phrased in a way that they do not feel threatened or that they are abnormal.
Along with a careful interview, other possible causes of symptoms should be evaluated. Because other psychiatric conditions may also be present, the interviewer must be sure to ask relevant questions for each possible condition.
Currently there are no laboratory tests available to evaluate for clinical depression. Three scales exist called the Beck Depression Inventory (BDI), the Child Depression Inventory (CDI), and the Reynolds Adolescent Depression Scale (RADS). These scales are good for monitoring progress, but cannot be used for actual diagnosis.
How is depression treated?
The treatment goals for depression are to shorten the period of depression, limit the amount of dysfunction and prevent recurrence. Based on the severity of the depression, different treatment options are available. The two primary treatment options are psychotherapy and medication.
Psychotherapy is the treatment of choice for patients with mild to moderate depression. Especially for adolescents, specific psychotherapies including cognitive, cognitive behavioral and interpersonal therapies have been shown to be effective in the treatment of depression. For mild or moderate depression, there is a consensus that psychotherapy is as effective as medication. The cost of psychotherapy, however, may limit access to this treatment modality.
Medications are widely prescribed to adolescents with depression. Although medications are usually not used for mild depression, they are more frequently prescribed for moderate depression and strongly encouraged for teens afflicted with severe depression. For patients with severe depression both psychotherapy and medication are usually required in combination. Combined treatment improves coping skills, self-esteem, and improved family and peer relationships.
Treatment for major depressive disorder is monitored through three stages: acute, continuation, and maintenance. Acute treatment generally lasts six to twelve weeks and consists of an assessment of suicide risk and initial psychotherapy. During this initial phase it is important to have close follow up with the clinician. The continuation phase goes on for the next six to twelve months with careful assessment and monitoring to ensure there is no relapse of the severe depression. Finally, maintenance visits consists of medication monitoring and periodic progress visits. In severe cases of depression, day treatment programs and intensive family interventions may be required.
The major types of medications available for treatment of depression in adolescents are selective serotonin re-uptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). SSRIs are relatively safe as long as the adolescent is closely monitored. Since TCAs are potentially toxic to an individual’s heart in an overdose, their use must be carefully monitored.
SSRIs are now more widely prescribed for adolescent depression because of their effectiveness and safety. The SSRIs are usually given daily in the morning with breakfast. About ten percent of individuals may become sedated; in that case, the medication may be administered at bedtime. Other side effects may include nausea, diarrhea, headache and insomnia. The following SSRIs may be used to treat adolescent depression:
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Citalopram
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Fluoxetine
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Fluvoxamine
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Paroxetine
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Sertraline
Alternative antidepressants may also be used including buproprion, mirtazapine, nefazodone and venlafaxine. There have been published studies that support the use, safety and efficacy of SSRIs in the treatment of adolescent depression. For adolescents diagnosed with SAD, a special light box may be offered as therapy. For about ½ hour daily, the teen sits a few feet away from a very bright fluorescent light. Some individuals report improved mood within two days of initiating light therapy.
How is depression prevented?
A strong social network may help to prevent depression; this may also include strong connections to spirituality. Exercise, either brief periods of intense activity or involvement with sports may produce a sense of well being in adolescents. Positive outcomes from exercise including weight loss and increased muscle tone can boost self-esteem and be helpful in preventing depression.
Related topics:
Academics, antidepressants, attention deficit disorder, body image, chronic illness, counseling, exercise, growth and development, psychotherapy, risk-taking, self-esteem
