Only in the past two decades has depression in children been taken very seriously. Research has revealed that depression is occurring earlier in life today than in past decades.24 In addition, research has shown that early onset depression often persists, recurs, and continues into adulthood, and that depression in youth may also predict more severe illness in adult life.25 An NIMH sponsored study of 9 to 17 year olds estimates that the prevalence of any depressive disorder is more than 6 percent in a six month period, with 4.9 percent having major depression.26 Before puberty, boys and girls are equally likely to develop depressive disorders. After age 14, however, females are twice as likely as males to have major depression or dysthymia.27 The risk of developing bipolar disorder remains approximately equal for males and females throughout adolescence and adulthood.
The depressed younger child may say he is sick, refuse to go to school, cling to a parent, or worry that the parent may die. The depressed older child may sulk, get into trouble at school, be negative and grouchy, and feel misunderstood. Signs of depressive disorders in young people are often viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely “label” a young person with a mental illness diagnosis. However, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development. Depression in young people frequently co occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, as well as with other serious illnesses such as diabetes.28,29
Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents, there is also an increased risk for substance abuse and suicidal behavior.25,30,31 Unfortunately, these disorders often go unrecognized by families and physicians alike.
Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that for adults, a number of recent studies have confirmed the short term efficacy and safety of treatments for depression in youth. An NIMH funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy is the most effective treatment.32 Additional research is needed on how best to incorporate these treatments into primary care practice.
Bipolar disorder, although rare in young children, can appear in both children and adolescents.33 The unusual shifts in mood, energy, and functioning that are characteristic of bipolar disorder may begin with manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the illness. Twenty to 40 percent of adolescents with major depression go on to reveal bipolar disorder within five years after the onset of depression.
Depression in children and adolescents is associated with an increased risk of suicidal behaviors.25,34 This risk may rise, particularly among adolescent males, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.35 In 2002, suicide was the third leading cause of death among young males, age 15 to 24.36 NIMH supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may die by suicide in the young adult years.25 Therefore, it is important for doctors and parents to take seriously any remarks about suicide.
NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limitations on young people’s access to lethal agents ¬including firearms and medications¬ may hold the greatest suicide prevention value.
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2. Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab Stone ME, Lahey BB, Bourdon K, Jensen PS, Bird HR, Canino G, Regier DA. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC 2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865 77.
3. Angold A, Worthman CW. Puberty onset of gender differences in rates of depression: a developmental, epidemiologic and neuroendocrine perspective. Journal of Affective Disorders, 1993; 29: 145 58.
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5. Kovacs M. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care, 1997; 20(1): 36 44.
6. Birmaher B, Brent DA, Benson RS. Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37(11): 1234 8.
7. Ryan ND, Puig Antich J, Ambrosini P, Rabinovich H, Robinson D, Nelson B, Iyengar S, Twomey J. The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 1987; 44(10): 854 61.
8. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J; 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; 292(7): 807 20.
9. McClellan J, Werry J. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(Suppl 10): 157S 76S.
10. Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339 48.
11. Shaffer D, Craft L. Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 1999; 60(Suppl 2): 70 4; discussion 75 6, 113 6.
12. Kochanek KD, Murphy SL, Anderson, RN, Scott, C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004.