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Depression in Children and Adolescents

by Josephine Elia, MD

Depression is a feeling of sadness or irritability intense enough to interfere with functioning or to cause considerable distress. It may follow a recent loss or other sad event but is out of proportion to that event and persists beyond an appropriate length of time (see also Depression).

  • Physical disorders, life experiences, and heredity can contribute to depression.

  • Affected children and adolescents may be sad, disinterested, and sluggish or overactive, aggressive, and irritable.

  • Doctors base the diagnosis on symptoms as reported by the child, parents, and teachers and do tests to check for other disorders that can be causing the symptoms.

  • For adolescents, a combination of psychotherapy and antidepressants is usually most effective, but for younger children, psychotherapy alone is usually tried first.

Sadness and unhappiness are common human emotions, particularly in response to troubling situations. For children and adolescents, such situations may include the death of a parent, divorce, a friend moving away, difficulty adjusting to school, and difficulty making friends. However, feelings of sadness are sometimes out of proportion to the event or persist far longer than expected. In such cases, particularly if the feelings cause difficulties in day-to-day functioning, children may have depression. Like adults, some children become depressed even when no unhappy life events occur. Such children are more likely to have family members with mood disorders (a family history).

Depression occurs in as many as 2% of children and 5% of adolescents.

Doctors do not know exactly what causes depression, but chemical abnormalities in the brain are probably involved. Some tendency to develop depression is inherited. A combination of factors, including life experiences and a genetic tendency (vulnerability), seems to contribute. Sometimes another disorder, such as an underactive thyroid gland or drug abuse, is part of the cause.

Depression includes several disorders:

  • Major depressive disorder

  • Disruptive mood dysregulation disorder

  • Persistent depressive disorder (dysthymia)

Did You Know...

  • Some children with depression are overactive and irritable rather than sad.


As in adults, the severity of depression in children varies greatly.

Major depressive disorder

Children typically have feelings of overwhelming sadness or irritability, worthlessness, and guilt. They lose interest in activities that normally give them pleasure, such as playing sports, watching television, playing video games, or playing with friends. They may profess intense boredom. Many of these children also complain of physical problems, such as stomachache or headache.

Appetite may increase or decrease, often leading to substantial changes in weight.

Sleep is usually disturbed. Children may have insomnia, sleep too much, or be troubled by frequent nightmares.

Depressed children are often not energetic or physically active. However, some, particularly younger children, have seemingly contradictory symptoms, such as overactivity and aggressive, very irritable behavior. Some children seem more irritable than sad.

Symptoms typically interfere with the ability to think and concentrate, and schoolwork usually suffers. They may lose friends. Children may have suicidal thoughts, fantasies, and attempts.

Even without treatment, children with major depressive disorder may get better in 6 to 12 months. However, the disorder often recurs, particularly if the first episode was severe or occurred when children were young.

Disruptive mood dysregulation disorder

Children are irritable most of the time for a long time, and their behavior is frequently out of control. They frequently lose their temper, often by expressing rage, destroying property, or physically hurting others. This disorder usually begins when children are 6 to 10 years old.

Many of these children also have other disorders, such as

When these children become adults, they may develop depression.

Persistent depressive disorder

This disorder resembles major depressive disorder, but symptoms are not usually as intense and last a year or longer.


  • Interviews or structured questionnaires

  • Tests to check for other causes of symptoms

To diagnose depression, doctors rely on several sources of information, including an interview with the child or adolescent and information from parents and teachers. Sometimes doctors use structured questionnaires (see Diagnosis) to help distinguish depression from a normal reaction to an unhappy situation. Doctors try to find out whether family or social stresses may have precipitated the depression. Doctors also ask specifically about suicidal behavior, including thoughts and talk about suicide.

Doctors do tests to determine whether a physical disorder, such as an abnormal thyroid gland or drug abuse, is the cause.


  • For most adolescents, psychotherapy and antidepressants

  • For younger children, psychotherapy followed, if needed, by antidepressants

  • Guidance for family members and school staff

Treatment depends on the severity of symptoms. Any child who has suicidal thoughts should be closely supervised by experienced mental health care practitioners. If risk of suicide is high enough, children require brief hospitalization to keep them safe.

For most adolescents, a combination of psychotherapy and drugs is more effective than either alone. But for younger children, treatment is less clear. Psychotherapy alone may be tried first, and drugs are used only if needed. Individual psychotherapy, group therapy, and family therapy may be beneficial. Doctors also advise family members and the school on how they can help children continue to function and learn.

Antidepressant drugs help correct chemical imbalances in the brain. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, and paroxetine (see Table: Drugs Used to Treat Depression), are the drugs most commonly prescribed for depressed children and adolescents. Tricyclic antidepressants, such as imipramine, are much less effective in children than adults and have more side effects, so they are rarely used in children.

In children, as in adults, depression often recurs. Children and adolescents should be treated for at least 1 year after symptoms have disappeared.

Antidepressant drugs and suicide

Recently, there has been concern that antidepressants may cause a slight increase in the risk of suicidal thinking and behavior in children and adolescents (see also Suicidal Behavior in Children and Adolescents). This concern has led to an overall decrease in the use of antidepressants in children. However, this decrease in the use of antidepressants has been associated with an increase in the rate of death by suicide, perhaps because depression is then not adequately treated in some children.

Studies have been done to try to settle this issue. They found that suicidal thought and attempts may increase very slightly in children who take antidepressants. However, most doctors believe that the benefits outweigh the risks and that children with depression often benefit from drug treatment as long as doctors and family members are alert for worsening symptoms or suicidal thoughts.

Whether or not drugs are used, suicide is always a concern in a child or adolescent with depression. The following can help reduce the risk:

  • Parents and mental health care practitioners should talk about the issues in depth.

  • The child or adolescent should be supervised appropriately.

  • Regular psychotherapy sessions should be included in the treatment plan.

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