Depression is a feeling of sadness or irritability intense enough to interfere with functioning. 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 Mood Disorders: 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.

Did You Know... Some children with depression are overactive and irritable rather than sad.

Symptoms

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

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. Children may have suicidal thoughts, fantasies, and attempts.

Symptoms of Depression in Children
Feeling sad or irritable Having no interest in favorite activities Withdrawing from friends and social situations Being unable to enjoy things Feeling rejected and unloved Not sleeping well and having nightmares or sleeping too much Blaming themselves Losing their appetite and weight Thinking about suicide Giving away valued possessions Complaining of new physical symptoms Making lower grades in school

Diagnosis

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 Mood Disorders: 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.

Treatment

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, psychotherapy alone may be tried first, and drugs are used only if needed. Individual psychotherapy, group therapy, and family therapy may be beneficial.

Daily use of specialized artificial light (phototherapy) may be useful if depression is related to the seasons. In late fall and winter, the reduced amount of daylight causes hormonal changes that can contribute to depression. Phototherapy is most often used with drugs or psychotherapy in children and adolescents who have episodes of depression in winter.

Antidepressant drugs help correct chemical imbalances in the brain. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, and paroxetine (see Table on Mood Disorders: 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.

Antidepressant Drugs and Suicide: Recently, there has been concern that antidepressants may increase the risk of suicidal thinking and behavior in children and adolescents, particularly during the first few weeks after the drugs are started. 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. Some experts hypothesize that antidepressants first cause agitation and anxiety before they relieve depression. During this initial period, children and adolescents may be more likely to talk about their suicidal feelings and sometimes even act on them. However, when depression is eventually relieved, the children are then less likely to commit suicide. Studies are being done to try to settle this issue, but doctors tend to agree that children with depression often benefit from drug treatment as long as they and family members are alert for worsening symptoms or suicidal thoughts.

Last full review/revision February 2009 by Hugh F. Johnston, MD