IACAPAP e-Textbook of Child and Adolescent Mental Health.
J. M. Rey (2018)
Chapter E.1
Depression in children and adolescents

Epidemiology

Prevalence varies depending on the population, the period considered, informant, and criteria used for diagnosis. Most countries concur that about 1 to 2% of pre-pubertal children and about 5% of adolescents suffer from clinically significant depression at any one time. The cumulative prevalence (accumulation of new cases in previously unaffected individuals) is higher.

Gender and culture

The ratio of depression in males and females is similar in pre-pubertal children. It becomes about twice as common among females during adolescence.

Burden of illness

Depression poses a substantial burden to the individual suffering from this disorder and the society at large. Interpersonal relationships are particularly likely to suffer when someone is depressed. Depression is likely to progress into a chronic, recurring disease if not treated.

The burden of depression is increased because it appears to be associated with behaviours linked to other chronic diseases, although the nature of this association is unclear.

Age of onset and course

Depressed patients can display symptoms of depression at any age. The pattern varies slightly according to developmental stage.

Age at onset does not seem to define separate depressive subgroups. Earlier onset is associated with multiple indicators of greater illness burden in adulthood across a wide range of domains.

Adolescents often have a reactive affect and can, with effort, hide their symptoms.

Course

Clinical depression in youth follows a recurring course. An episode of depression in clinically referred patients last 7 to 9 months on average, but it can be shorter in non-referred community samples. Depressive episodes are, on average, a spontaneously remitting illness. Recurrence is high even after treatment.

Predictors of recurrence include: poorer response to treatment, greater severity, chronicity, previous episodes, comorbidity, hopelessness, negative cognition style, family problems, low socioeconomic status, and exposure to abuse or family conflict

Subtypes of depression

Different types of depression may have implications for treatment and prognosis.

Etiology and risk factors

The etiology of depression is complex, multifactorial, and the object of much academic argument.

Depression in youth appears to be the result of complex interactions between biological vulnerabilities and environmental influences. Biological vulnerabilities may result from children’s genetic endowment and form prenatal factors. Environmental influences include children’s family relationships, cognitive style, stressful life events, and school and neighbourhood characteristics.

Comorbidity

Comorbidity is the simultaneous occurrence of two or more distinct illnesses in the one individual. Depression comorbid with other disorders frequently in children and adolescents.

Berkson effect: comorbidity is particularly the cause in clinical settings because the likelihood of referral is a function of the combined likelihood of referral for each disorder individually.

Patients with comorbid disorders show greater impairment than those with a single diagnosis. It is also associated with worse adult outcomes.

Psychiatric disorders that often comorbid with depression include: anxiety disorders, conduct problems, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder, learning difficulties, and post-traumatic stress disorder

Suffering from a depressive episode increases the risk of further depressive episodes (homotypic continuity) and of anxiety disorders (heterotypic continuity).

Depression and personality style

Personality traits become progressively established during adolescence and early adulthood.Personality styles can influence the presentation and manifestation of a depressive illness. Adolescents’ underlying personality features are amplified when they are depressed.

Borderline personality styles are particularly relevant to depression. Individuals with these traits are dysphoric and extremely sensitive to rejection. The fears of abandonment can be accompanied by intense but usually brief episodes of sadness, anger, or irritability, which sometimes culminate in incidents of self-harm. Both a depressive disorder and borderline personality traits or disorder can coexist.

Depression and suicidal behaviour

Suicidal thoughts are common among the young. Depression is the strongest individual risk factor for suicide.

Risk increases if there have been suicides in the family, the young person has attempted suicide previously, there are other comorbid psychiatric disorders, impulsivity and aggression, there is access to lethal means, and/or they have experienced negative events

Diagnosis

Depression in children and adolescents is often not detected or treated. Young people tend to present initially with behavioural or physical complaints which may obscure the typical depressive symptoms seen in adults.

Complaints that should alert clinicians to the possibility of depression include: irritability or cranky mood, chronic boredom or loss of interest in previously enjoyed leisure activities, social withdrawal, avoiding school, decline in academic performance, change in sleep-wake pattern, frequent unexplained complaints of feeling sick, headaches, stomach-aches, development of behavioural problems, and/orbusing alcohol or other substances

It is important to ascertain if the current problems represent a change from the teenager’s previous level of functioning or character.

A key aspect in the assessment of any depressed youth is the evaluation of risk, particularly of suicide.

Informant

Parents and teachers tend to under-estimate depressive feelings in children while young persons may overestimate them. Reports and questionnaire data from different informants often disagree. It is essential to interview the child, often on several occasions, to obtain an accurate picture of how the young person is feeling. Clinicians should give more weight to the young person’s report when diagnosing depression, though information form parents and teachers should also be considered.

Severity

Evaluating the severity of a depressive episode is important because treatment guidelines use severity as one of the yardsticks to indicate what treatment should be administered first.

Differential diagnosis

Sadness and unhappiness are components of normal human experience. Sometimes these feelings are so intense and persistent that individuals are unable to function at the level to which they are accustomed. It is in these situations that the labels of diagnosis are applied.

The issue is to distinguish clinical depression from the normal ups and downs.

Depression and normal adolescent behaviour

Teenagers are often perceived as normally being moody, irritable, anhedonic and bored.

Physical illness or medication

A variety of medical conditions, treatments and substances can mimic depression in children and adolescents. These include: medications, substances of abuse, infections, neurologic disorders, and endocrine

Unipolar or bipolar?

There are characteristics that increase suspicion that a depressive episode may be bipolar. These are 1) A family history of bipolar disorder 2)The presence of psychotic symptoms or catatonia

A bipolar disorder diagnosis should not be made unless there is a history of at least one non drug-induced manic, hypomanic or mixed episode.

Subtance use disorders

It is always important to clarify whether depressive symptoms are etiologically related to the ingestion of substances. It is expected that symptoms would disappear after a few days of abstinence when they are substance-induced. If depressive symptoms persists or precede the onset of substance-use, one would suspect that a depressive disorder is present and comorbid with substance use.

Schizophrenia

When adolescents present with depressive symptoms as well as hallucinations or delusions it is important to clarify whether schizophrenia or psychotic depression is the appropriate diagnosis.

Features suggestive of psychotic depression include: 1) A family history of depression or bipolar disorder 2) Relatively rapid onset without a prodromal period 3)The presence of mood congruent hallucinations 4)Delusions

ADHD and disruptive behaviour disorders

Irritability and demoralization are very common symptoms in children who suffer from ADHD, oppositional defiant disorder or conduct problems, often in a context of significant family dysfunction, poverty, neglect, foster care, or institutionalisation. In these cases is it difficult to establish whether demoralization is the result of the child’s plight or a manifestation of clinical depression.

If symptoms meet criteria for depression, a comorbid diagnosis of depression is encouraged by the DSM system.

Adjustment disorder with depressed mood and bereavement

Clinicians often diagnose adjustment disorder when the onset of symptoms occurs following a significant life events. This is correct only if clinically significant depressive symptoms or impairment occur within three months of identifiable stressors and do not meet criteria for major depression or bereavement. It is expected that symptoms will disappear within six months once stressors have ceased.

Bereavement can present with a clinical picture very similar to a depressive episode but depression should not be diagnosed unless symptoms are severe, persistent, and incapacitating.

Rating scales

There are numerous rating scales for child and adolescent depression. The most widely used rating scales are self-rating, most having child, parent and teacher versions. These instruments are mostly used for screening purposes or to assess preponed to treatment over time.

Barriers in the implementation of evidence-based care in low-income countries

Not only are there few child and adolescent psychiatrists, but also the profession itself is not formally recognized as speciality in many countries.

Parent’s, teachers’ and health professionals’ knowledge of, and attitudes towards depression may lead to delayed or inappropriate help-seeking, or may hamper adherence to clinicians’ recommendations.