(see also See also Mood Disorders: Depressive Disorders.)

Depressive disorders in children and adolescents are characterized by a pervasive and abnormal mood state that consists of sadness or irritability and that is severe or persistent enough to interfere with functioning or cause considerable distress. Decreased interest or pleasure in activities may be as apparent as or even more apparent than mood abnormalities. Diagnosis is by history and examination. Treatment is with antidepressants, psychotherapy, or both.

Major depression occurs in as many as 2% of children and 5% of adolescents. Rates for other depressive disorders are unknown. The exact cause of depression in children and adolescents is unknown, but in adults, it is believed to result from interactions of genetically determined risk factors and environmental stress (particularly deprivation and loss early in life).

Symptoms and Signs

Basic manifestations are similar to those in adults but are related to typical concerns of children, such as schoolwork and play. Children may be unable to explain inner feelings or moods. Depression should be considered when previously well-performing children do poorly in school, withdraw from society, or commit delinquent acts.

Common symptoms include

• A sad appearance
• Excessive irritability
• Apathy and withdrawal
• Reduced capacity for pleasure (often expressed as profound boredom)
• Feeling rejected and unloved
• Somatic complaints (eg, headaches, abdominal pain, insomnia)
• Persistent self-blame

In some children with major depressive disorder, the predominant mood is irritability rather than sadness (an important difference between childhood and adult forms).

Other symptoms include anorexia, weight loss (or failure to achieve expected weight gain), sleep disruption (including nightmares), despondency, and suicidal ideation. The irritability associated with childhood depression may manifest as overactivity and aggressive, antisocial behavior.

In children with intellectual disability, depressive or other mood disorders may manifest as somatic symptoms and behavioral disturbances.

Major depression in adolescents is a risk factor for academic failure, substance abuse, and suicidal behavior (see Mental Disorders in Children and Adolescents: Suicidal Behavior in Children and Adolescents). While depressed, children and adolescents tend to fall far behind academically and lose important peer relationships. Untreated, major depression may remit in 6 to 12 mo, but recurrences are common.

Diagnosis

• Clinical evaluation

Diagnosis is based on symptoms and signs. A careful review of the history and appropriate laboratory tests are needed to exclude other disorders (eg, infectious mononucleosis, thyroid disorders, drug abuse). History should include causative factors such as domestic violence, sexual abuse and exploitation, and drug adverse effects. Questions about suicidal behavior (eg, ideation, gestures, attempts) should be asked.

Other mental disorders that can cause depressive symptoms (eg, anxiety, bipolar disorders) must be considered. Some children who eventually develop a bipolar disorder or schizophrenia may present initially with major depression.

After depression is diagnosed, the family and social setting must be evaluated to identify stresses that may have precipitated depression.

Treatment

• Concurrent measures directed at the family and school
• For adolescents, usually antidepressants plus psychotherapy
• For preadolescents, psychotherapy followed, if needed, by antidepressants

Appropriate measures directed at the family and school must accompany direct treatment of the child to enhance continued functioning and provide appropriate educational accommodations. Brief hospitalization may be necessary in acute crises, especially when suicidal behavior is identified.

For adolescents (as for adults), a combination of psychotherapy and antidepressants usually greatly outperforms either modality used alone. For preadolescents, the situation is much less clear. Most clinicians opt for psychotherapy in younger children; however, drugs can be used in younger children (fluoxetineSome Trade Names
PROZAC
SARAFEM
Click for Drug Monograph
can be used in children ≥ 8 yr), especially when depression is severe or has not previously responded to psychotherapy.

Usually, an SSRI (see Table 1: Mental Disorders in Children and Adolescents: SSRIs for Treating Children ≥ 12 Yr) is the first choice when an antidepressant is indicated. Children should be closely monitored for the emergence of behavioral side effects (eg, disinhibition, behavioral activation—see footnote in Table 1: Mental Disorders in Children and Adolescents: SSRIs for Treating Children ≥ 12 Yr). Adult-based research has suggested that antidepressants that act on both the serotonergic and adrenergic/dopaminergic systems may be modestly more effective; however, such drugs (eg, duloxetineSome Trade Names
CYMBALTA
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, venlafaxineSome Trade Names
EFFEXOR
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, mirtazapineSome Trade Names
REMERON
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; certain tricyclics, particularly clomipramineSome Trade Names
ANAFRANIL
Click for Drug Monograph
) also tend to have more adverse effects. Such drugs may be especially useful in treatment-resistant cases. Nonserotonergic antidepressants such as bupropionSome Trade Names
WELLBUTRIN
ZYBAN
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and desipramineSome Trade Names
NORPRAMIN
Click for Drug Monograph
may also be used with an SSRI to enhance efficacy.

There are recent concerns that antidepressants may increase risk of suicidality in a few children and adolescents. These drugs are now labeled with warnings about suicidality. Paradoxically, several studies suggest that, overall, use of antidepressants significantly reduces risk of suicide. How to interpret these contradictory findings is unclear. However, if suicide is a concern, the following should be done to reduce risk:

• Parents and mental health care practitioners should discuss the issues in depth.
• The child or adolescent should be supervised at an appropriate level.
• Psychotherapy with regularly scheduled appointments should be included in the treatment plan.

As in adults, relapse and recurrence are common. Children and adolescents should remain in treatment for at least 1 yr after symptoms have remitted. Most experts recommend that children who have experienced ≥ 2 episodes of major depression be treated indefinitely.

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

Content last modified February 2012