Depression and Mood Disorders
All too common in children & adolescents
Depression and mood disorders are a significant concern for children and adolescents. The Surgeon General’s 1999 report on Mental Health (ref. 1) concludes that at any given time between 10 and 15 percent of the child and adolescent population have “some symptoms of depression.” The report also asserts that best estimates suggest that 5% of children and teens (between 5 and 17) have a Major Depression while approximately 3% of adolescents have a Dysthymic disorder. For Bipolar Disorder, there is evidence that the rates for adolescents may be similar to that of adults (ref. 2). An NIMH-supported study suggest that 1% of adolescents were found to have met criteria for Bipolar Disorder or Cyclothymia (ref. 3). More recent estimates have suggested that the percentage of children and adolescents with depression and mood disorders may be on the increase.
Depressed/Bipolar children and adolescents are at risk
There is evidence that early onset of depression or a mood disorder is associated with a significant risk of recurrence of depression/mood disorders later in life. Research has found that early onset of bipolar disorder may be associated with a more severe form of the disorder (ref. 4 & 5) while early onset of depression (either Major Depression or Dysthymia) is associated with a very high rate of recurrence of depression (within 2 years 20-40% have a recurrence and by adulthood 70% will have relapse (ref. 1). In addition, there is strong evidence to suggest that depression and mood disorders greatly increase the risk for suicide and suicidal behavior, particularly in adolescents (ref. 1). Finally, depression (both Major Depressive disorder and Dysthymic disorder) are associated with fewer friendships, lower levels of achievement (academic and vocational) and higher levels of stress (ref. 1).
What causes depression and mood disorders in children & adolescents?
Increasingly, mental health professionals have recognized that depression and mood disorders have a strong inherited or genetic component. Studies have consistently found that depression and mood disorders (particularly bipolar disorder) run in families. Thus, it is not uncommon for a child or adolescent who is experiencing depression to have a parent or grandparent who has or is also diagnosed with depression (or a mood disorder).
In addition, there is evidence to suggest that stress, loss and trauma can place children and adolescents at risk for depression. Thus, if one believes that we are living in an increasingly stressful world, it is not surprising to conclude that more children and adolescents are at risk for depression.
Diagnosis of Depression and Mood Disorders
Diagnosing depression and mood disorders
Children and adolescents are often not good at clearly describing their symptoms. Many will deny problems, insist they are “fine,” in the face of overwhelming evidence that this is not the case. Therapists need to recognize that children and adolescents are poor “informants” and that parents (and other concerned adults, such as teachers) need to be consulted. In addition, many children and adolescents do not clearly connect their behavior to their feelings. Thus, children may not feel depressed, but may act out, behave in negative ways, and experience non-specific physical complaints (stomachaches and headaches), all of which may reflect a depression or mood disorder.
The process of diagnosis is further complicated by the fact that children and adolescents can experience depression differently than adults. Specifically, they may not “feel depressed” in the way adults do, e.g., feel sad or down. Rather, they may be irritable, complain about vague and non-specific aches and pains and act in disruptive or negative ways. While adolescents are more able to identify and describe their feelings, it is not uncommon for adolescents to experience depression differently than adults. Specifically, adolescents may experience an irritable mood rather than feeling depressed. In addition, they may be overly negative and cynical, adopting an almost nihilistic view of their lives and the world around them. Given these challenges the process of diagnosis may be more time consuming and complex. It is critical that therapists obtain parental input, particularly for those children and adolescents who are prone to denying and minimizing problems.
Diagnosing Bipolar Disorder
Making a diagnosis of a Bipolar Disorder for a child or adolescent is even more challenging. First, as with depression, symptom presentation may differ with children and adolescents. Children and adolescents are less mature, and as a result are prone to more volatile behaviors and moods. In addition, they are also more likely to act out feelings of upset. Thus, it is important to not read more into normal mood shifts and emotional volatility. Second, differential diagnosis (determining which disorder is present) is complicated by the overlap between symptoms of Manic and Hypomanic episodes and ADHD (Attention deficit hyperactivity disorder). Impulsive, reckless, and disruptive behavior, are symptoms of both disorders. In addition, children and teens with ADHD are thought to be more emotional, have been found to be at risk for defiant behavior, and are prone to repeating problematic behaviors (see section on ADHD). Similarly, children and adolescents who are depressed may exhibit irritable and disruptive behavior. Third, there are no clearly established criteria for diagnosing Bipolar Disorder in children and adolescents. Given these concerns, caution and thoroughness are the watchwords in diagnosing Bipolar Disorder in children and adolescents. It is important to not over diagnose children and adolescents and to be as sure as possible that current symptoms do not reflect a difficult temperament, significant family problems or stresses, or another disorder, such as ADHD or depression. It is also important to recognize that the presence of one or two symptoms does not not mean that one has a given disorder. Thus, to diagnosis a Bipolar Disorder in an adolescent or child we would assert that: multiple symptoms must be present; that symptoms need to disrupt functioning; and that symptoms need to occur in multiple settings and not be transient reactions to specific stresses or traumas.
Treatment of Depression and Mood Disorders in Children and Adolescents
Depression and Mood Disorders are treatable
While there is less research on the treatment of depression in children and adolescents than in adulthood (particularly on the treatment of bipolar disorder) there is evidence that the treatment approaches that work for adults also help children and adolescents. While there is not a substantial body of research studies have supported the use of Family therapy, Interpersonal therapy, and Cognitive Behavioral therapy with children and adolescents with depression (ref. 1, 7).
As with adults, there is evidence that the combination of therapy and medication is the most effective approach for treating depression in adolescents. Early results from the TADS (Treatment for Adolescents and Depression Study), a multi-site federally funded study of the treatment of moderate to severe depression in adolescents, supports the use of a combined treatment approach. Preliminary findings, from over 400 adolescents diagnosed with Major Depression found that the combination of psychotherapy (Cognitive Behavioral therapy) and medication (Prozac) to be the most effective treatment (ref. 8 & 9).
Given the research findings available the most reasonable course of treatment appears to be a combined approach, using both medication and therapy. However, as concerns have been raised about medication treatment with adolescents (see below) the option of utilizing psychotherapy alone is also a reasonable alternative.
The use of medication with depressive disorders is more controversial in children and adolescents. This controversy has increased with concerns that anti-depressants (SSRIs) may increase the risk of suicidal ideation in adolescents. In 2004 the Food and Drug Administration (FDA), following a review of the research on the treatment of children and adolescents with antidepressant medication, issued a public warning that antidepressant medications may induce suicidal behavior in adolescents. In the FDA review, no completed suicides occurred among nearly 2,200 children treated with SSRI medications. However, about 4 percent of those taking SSRIs experienced suicidal ideation (ref. 10). Other studies have reported more mixed results. For example, a recent review of studies suggests that the benefits of antidepressant medication outweigh the risks of not providing medication treatment (ref. 11). Given these findings further study is clearly needed. From a practical point of view, these findings suggest that antidepressant medication, when used with children and adolescents, should be closely monitored.
There is evidence supporting the idea that children and adolescents receiving antidepressant medication should be in therapy. Early findings from the TADS research project, noted above, suggest that the use of therapy, in this case CBT, in conjunction with medication, lowered the risk of suicidal thinking for adolescents. Specifically, those receiving medication alone had nearly twice the rate of suicidal thinking than those receiving medication plus CBT (15% to 8%) (ref. 8). This suggests that adding therapy provides additional safeguards for those vulnerable to suicide, according to the researchers.
In conclusion the available research suggests that the combination of therapy and medication appears to be the most effective and safest approach for the treatment of depression in children and adolescents.
Why family involvement in treatment is critical
Developmental issues with treatment
We cannot stress enough that children and adolescents are not miniature or youthful adults. Even the brightest adolescents do not have the emotional resources that they will have in adulthood. In addition, children and adolescents do not have the perspective that adults do.
Children and adolescents have more difficulty projecting ahead, realizing that their lives and situations will change, i.e., that they will graduate, make new friends, live in new places. As a result, they may be vulnerable to feeling more overwhelmed when depressed because they are not able to envision their lives changing. Similarly, children and adolescents are more impulsive than adults. This combination can be quite problematic. Specifically, depressed adolescents may believe that their lives will never change and be a risk for impulsive action (suicide attempts, substance abuse, or other reckless behavior) to try and manage or end their emotional pain.
Treatment is also complicated by the fact that:
children and adolescents are not as adept in talking about their feelings; they are less disciplined and thus less able to follow through on making changes in their lives; and they are more vulnerable to social and peer pressures. Thus, children, and even adolescents, may have trouble describing their symptoms and talking about their feelings. Second, children and adolescents have less self control than adults, are not as disciplined. As a result, they may have more difficulties following treatment recommendations and be more prone to wanting quit therapy. Third, peer and social pressures may increase adolescent acting out and resistance to treatment. Finally, children and adolescents are affected by their families. Parental vulnerabilities, family stresses, and family conflicts all may exacerbate problems and hamper treatment, if not addressed. It is also important to note that because depression and mood disorders appear to run in families that depressed teens and children may have one or more depressed parent.
Why family involvement is critical
All of the factors detailed above are an argument for family involvement (family therapy) as part of the treatment of children and adolescents who are depressed or experiencing mood disorders. Children and adolescents need/benefit from:
- Help defining their problems
- Support and encouragement
- Assistance in following through with treatment
- More structure, particularly if behavioral problems are present
- Resolution of family problems exacerbating depression
In conclusion, we believe that parental involvement is a necessary component in the treatment of children and adolescents with depression or a mood disorder.
Resources for Parents:
A non-profit website founded and directed by parents.
It offers solid information about bipolar disorder in children, as well as links to various resources.
A clearing house of Mental Health Resources.
This site offers information on childhood and adolescent depression and mood disorders, along with links to multiple resources. This site is run by a psychologist and tends to take a less “medical view” of depression and mood disorders. The main drawback of this site is the frequent annoying pop up ads.
Papolos, D, & Papolos, J, The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder (Revised and Expanded Edition) (Hardcover), Broadway Publishers, 2002. One of the most well-respected works on bipolar disorder in children and adolescents.
References for this article:
Ref. 1. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
Ref. 2. Child and Adolescent Bipolar Disorder: An Update from the National Institute of Mental Health; National Institute of Mental Health; Oct 2002.
Ref. 3. Lewinsohn PM, Klein DN, Seely JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry, 1995; 34(4): 454-63.
Ref . 4. Carlson GA, Jensen PS, Nottelmann ED, eds. Special issue: current issues in childhood bipolarity. Journal of Affective Disorders, 1998; 51: entire issue.
Ref . 5. Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(9): 1168-76.
Ref. 7. Johnson, S.M, & Lebow J. The coming of age of couple therapy: A decade review. Journal of Marital and Family Therapy, 200, 26, 9-24.
Ref. 8. The TADS Team. The Treatment for Adolescents with Depression Study (TADS): Long-term Effectiveness and Safety Outcomes. Archives of General Psychiatry. Oct 2007; VOL 64(10).
Ref. 9. Treatment for Adolescents with Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004 Aug. 18; 292(7):807-20.
Ref.10. Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. National Institute of Mental Health, www.NIMH
Ref. 11 Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA, MD. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment: A Meta-analysis of Randomized Controlled Trials. JAMA. 2007;297:1683-1696.