Depression in Children
A Fact Sheet for Physicians, August 2000
Depressive disorders, which include major depressive disorder (unipolar depression), dysthymic disorder (chronic, mild depression), and bipolar disorder (manic-depression), can have far reaching effects on the functioning and adjustment of young people. 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 1,2,3. Unfortunately, these disorders often go unrecognized by families and physicians alike. Signs of depressive disorders in young people often are 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. Yet early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development.
Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that concerning adults, a number of studies-mostly conducted in the last four to five years-have confirmed the short-term efficacy and safety of treatments for depression in youth. Larger treatment trials are needed to determine which treatments work best for which youngsters, and studies are also needed, however, on how to best incorporate these treatments into primary care practice.
Given the challenging nature of the problem, it is usually advisable to involve a child psychiatrist or psychologist in the evaluation, diagnosis, and treatment of a child or adolescent in whom depression is suspected.
This fact sheet, prepared by the National Institute of Mental Health (NIMH), the lead Federal agency for research on mental disorders, summarizes some of the latest scientific findings on child and adolescent depression and lists resources where physicians can obtain more information.
Scope of the Problem
A number of epidemiological studies have reported that up to 2.5 percent of children and up to 8.3 percent of adolescents in the U.S. suffer from depression 4. An NIMH-sponsored study of 9- to 17-year-olds estimates that the prevalence of any depression is more than 6 percent in a 6-month period, with 4.9 percent having major depression 5. In addition, research indicates that depression onset is occurring earlier in life today than in past decades 6. A recently published longitudinal prospective study found that early-onset depression often persists, recurs, and continues into adulthood, and indicates that depression in youth may also predict more severe illness in adult life 3. Depression in young people often co-occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, 7 and with physical illnesses, such as diabetes 8.
Suicide. Depression in children and adolescents is associated with an
increased risk of suicidal behaviors 3,9.
This risk may rise, particularly among adolescent boys, if the depression is
accompanied by conduct disorder and alcohol or other substance abuse 10. In 1997, suicide was the third leading cause of death
in 10- to 24-year-olds 11. NIMH-supported
researchers found that among adolescents who develop major depressive disorder,
as many as 7 percent may commit suicide in the young adult years 3. Consequently, it is important for doctors and parents to
take all threats of suicide seriously. 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
limiting young people's access to lethal agents-including firearms 12 and medications-may hold the greatest suicide
The diagnostic criteria and key defining features of major depressive disorder in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder may be more difficult in youth for several reasons. The way symptoms are expressed varies with the developmental stage of the youngster 1, 2. In addition, children and young adolescents with depression may have difficulty in properly identifying and describing their internal emotional or mood states. For example, instead of communicating how bad they feel, they may act out and be irritable toward others, which may be interpreted simply as misbehavior or disobedience. Research has found that parents are even less likely to identify major depression in their adolescents than are the adolescents themselves 13.
Symptoms of Major Depressive Disorder
Common to Adults, Children, and Adolescents 14
· Persistent sad or irritable mood
· Loss of interest in activities once enjoyed
· Significant change in appetite or body weight
· Difficulty sleeping or oversleeping
· Psychomotor agitation or retardation
· Loss of energy
· Feelings of worthlessness or inappropriate guilt
· Difficulty concentrating
· Recurrent thoughts of death or suicide
Five or more of these symptoms must persist for 2 or more weeks
before a diagnosis of major depression is indicated.
Signs That May Be Associated with Depression in Children and Adolescents
· Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomachaches or tiredness
· Frequent absences from school or poor performance in school
· Talk of or efforts to run away from home
· Outbursts of shouting, complaining, unexplained irritability, or crying
· Being bored
· Lack of interest in playing with friends
· Alcohol or substance abuse
· Social isolation, poor communication
· Fear of death
· Extreme sensitivity to rejection or failure
· Increased irritability, anger, or hostility
· Reckless behavior
· Difficulty with relationships
While the recovery rate from a single episode of major depression
in children and adolescents is quite high 15,
episodes are likely to recur 16. In addition,
youth with dysthymic disorder are at risk for developing major depression 17. Prompt identification and treatment of depression can
reduce its duration and severity and associated functional impairment.
There are several tools that are useful for screening children and adolescents for possible depression. They include the Children's Depression Inventory (CDI) 18 for ages 7 to 17; and, for adolescents, the Beck Depression Inventory (BDI) 19 and the Center for Epidemiologic Studies Depression (CES-D) Scale 20. When a youngster screens positive on any of these instruments, a comprehensive diagnostic evaluation by a mental health professional is warranted. The evaluation should include interviews with the youth, parents, and when possible, other informants such as teachers and social services personnel.
In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys to develop depression 4. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression 21. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.
Other risk factors include:
· Stress 22
· Cigarette smoking 22
· A loss of a parent or loved one 23
· Break-up of a romantic relationship 24
· Attentional, conduct or learning disorders 25
· Chronic illnesses, such as diabetes 8
· Abuse or neglect 26
· Other trauma, including natural disasters 27
Treatment for depressive disorders in children and adolescents often involves short-term psychotherapy, medication, or the combination, and targeted interventions involving the home or school environment. There remains, however, a pressing need for additional research on the effectiveness of psychosocial and pharmacological treatments for depression in youth. While data from adults indicate the need for maintenance treatment after episode recovery in order to prevent recurrences, the value of such treatment in children and adolescents has yet to be determined through research.
Psychotherapy. Recent research shows that certain types of short-term
psychotherapy, particularly cognitive-behavioral therapy (CBT), can help
relieve depression in children and adolescents 1,28,29. CBT is based on the premise that
people with depression have cognitive distortions in their views of themselves,
the world, and the future. CBT, designed to be a time-limited therapy, focuses
on changing these distortions. An NIMH-supported study that compared different
types of psychotherapy for major depression in adolescents found that CBT led
to remission in nearly 65 percent of cases, a higher rate than either
supportive therapy or family therapy. CBT also resulted in a more rapid
treatment response 30. Another specific
psychotherapy, interpersonal therapy (IPT), focuses on working through
disturbed personal relationships that may contribute to depression. IPT has not
been well investigated in youth with depression; however, one controlled study
found that IPT led to greater improvement than clinical contact alone 31.
Continuing psychotherapy for several months after remission of symptoms may help patients and families consolidate the skills learned during the acute phase of depression, cope with the after-effects of the depression, effectively address environmental stressors, and understand how the young person's thoughts and behaviors could contribute to a relapse 1.
Medication. Research clearly demonstrates that antidepressant
medications, especially when combined with psychotherapy, can be very effective
treatments for depressive disorders in adults 32.
Using medication to treat mental illness in children and adolescents, however,
has caused controversy. Many doctors have been understandably reluctant to
treat young people with psychotropic medications because, until fairly
recently, little evidence was available about the safety and efficacy of these
drugs in youth. In the last few years, however, researchers have been able to
conduct randomized, placebo-controlled studies with children and adolescents.
Some of the newer antidepressant medications, specifically the selective
serotonin reuptake inhibitors (SSRIs), have been shown to be safe and
efficacious for the short-term treatment of severe and persistent depression in
young people, although large scale studies in clinical populations are still
needed. So far, there are two controlled studies showing efficacy of fluoxetine
and paroxetine, respectively 33,34.
It is important to note that available studies do not support the efficacy of
tricyclic antidepressants (TCAs) for depression in youth 35,36.
Medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy, those who are unable to undergo psychotherapy, those with psychosis, and those with chronic or recurrent episodes. Following remission of symptoms, continuation treatment with medication and/or psychotherapy for at least several months may be recommended by the psychiatrist, given the high risk of relapse and recurrence of depression. Discontinuation of medications, as appropriate, should be done gradually over 6 weeks or longer 1.
NIMH has initiated a large-scale, controlled clinical trial at 10 sites across the U.S. to compare the long-term effectiveness of fluoxetine, CBT, and the combination of these interventions for treatment of depression in adolescents. More information about this trial, called the Treatment of Adolescents with Depression Study, and others can be found through the Clinical Trials page of the NIMH web site http://www.nimh.nih.gov/studies/index.cfm.
Talking With Parents
It is very important for parents to understand their child's depression and the treatments that may be prescribed. Physicians can help by talking with parents about their questions or concerns, reinforcing that depression in youth is not uncommon, and reassuring them that appropriate treatment with psychotherapy, medication, or the combination can lead to improved functioning at school, with peers, and at home with family. In addition, referring the youth and family to a mental health professional and to the information resources listed at the back of this publication can help to enhance recovery.
Other Types of Depression In Children and Adolescents
· Bipolar Disorder
Although rare in young children, bipolar disorder-also known as
manic-depressive illness-can appear in both children and adolescents 37. Bipolar disorder, which involves unusual shifts in
mood, energy, and functioning, may begin with either manic, depressive, or
mixed manic and depressive symptoms. It is more likely to affect the children
of parents who have the disorder. Twenty to 40 percent of adolescents with
major depression develop bipolar disorder within 5 years after depression onset
Existing evidence indicates that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder 38. When the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may have features of these disorders as initial symptoms. In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode, and to have a more episodic pattern with relatively stable periods between episodes. There is also less co-occurring ADHD or CD among those with later onset illness.
Bipolar Disorder: Manic Symptoms 14,37
· Severe changes in mood-either extremely irritable or overly silly and elated
· Overly-inflated self-esteem; grandiosity
· Increased energy
· Decreased need for sleep-able to go with very little or no sleep for days without tiring
· Increased talking-talks too much, too fast; changes topics too quickly; cannot be interrupted
· Distractibility-attention moves constantly from one thing to the next
· Hypersexuality-increased sexual thoughts, feelings, or behaviors; use of explicit sexual language
· Increased goal-directed activity or physical agitation
· Disregard of risk-excessive involvement in risky behaviors or activities
A child or adolescent who appears to be depressed and exhibits
ADHD-like symptoms that are very severe, with excessive temper outbursts and
mood changes, should be evaluated by a psychiatrist or psychologist with
experience in bipolar disorder, particularly if there is a family history of
the illness. This evaluation is especially important since psychostimulant
medications, often prescribed for ADHD, may worsen manic symptoms. There is also
limited evidence suggesting that some of the symptoms of ADHD may be a
forerunner of full-blown mania 38.
The essential treatment of bipolar disorder in adults involves the use of appropriate doses of mood stabilizing medications, typically lithium and/or valproate, which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Treatment of children and adolescents diagnosed with bipolar disorder is based mainly on experience with adults, since as yet there is very limited data on the safety and efficacy of mood stabilizing medications in youth. Researchers currently are evaluating both pharmacological and psychosocial interventions for bipolar disorder in young people.
Bipolar Disorder: A Warning About Antidepressants and Psychostimulants
Using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer, such as lithium or valproate 37. In addition, using psychostimulant medications to treat ADHD or ADHD-like symptoms in a child or adolescent with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a child psychiatrist should be consulted, and treatment for bipolar disorder should be considered. Physicians should be aware of the signs and symptoms of mania so that they can educate families on how to recognize these and report them immediately.
According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20 39. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients prescribed valproate should be monitored carefully.
· Dysthymic disorder (or dysthymia)
This less severe yet typically more chronic form of depression is
diagnosed when depressed mood persists for at least one year in children or
adolescents and is accompanied by at least two other symptoms of major
depression 14. Dysthymia is associated with an
increased risk for developing major depressive disorder, bipolar disorder, and
substance abuse 4,17. Treatment
of dysthmia may prevent the deterioration to more severe illness 1. If dysthymia is suspected in a young patient, referral
to a mental health specialist is indicated for a comprehensive diagnostic
evaluation and appropriate treatment.
National Institute of Mental Health
Office of Communications and Public Liaison
Information Resources and Inquiries Branch
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
Mental Health FAX 4U: (301) 443-5158
NIMH home page: www.nimh.nih.gov
American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue, N.W.
Washington, DC 20016
American Psychiatric Association
1400 K Street, N.W.
Washington, DC 2005
American Psychological Association
750 First Street, N.E.
Washington, DC 20002
Child & Adolescent Bipolar Foundation
1187 Willmette Avenue, PMB #331
Willmette, IL 60091
National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
(800) 950-NAMI (-6264)
National Depressive and Manic-Depressive Association
730 N. Franklin Street, Suite 501
Chicago, IL 60610-3526
National Mental Health Association
1021 Prince Street
Alexandria, VA 22314
(800) 969-NMHA (-6642)
National Institutes of Health,
National Library of Medicine's clinical trials database
1 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. See also www.aacap.org/clinical/Depres~1.htm.
2 Ryan ND, Puig-Antich J, Ambrosini P, et al. The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 1987; 44: 854-61.
3 Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grown up. Journal of the American Medical Association, 1999; 281:1701-13.
4 Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(11): 1427-39.
5 Shaffer D, Fisher P, Dulkan MK, et al. The NIMH Diagnostic Interview Schedule for Children version 2.3 (DISC-2.3): description, acceptability, prevalence rates and performance in the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865-77.
6 Klerman GL, Weissman MM. Increasing rates of depression. Journal of the American Medical Association, 1989; 261: 2229-35.
7 Angold A, Costello EJ. Depressive comorbidity in children and adolescents: empirical, theoretical, and methodological issues. American Journal of Psychiatry, 1993; 150(12): 1779-91.
8 Kovacs M. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care, 1997; 20(1): 36-44.
9 Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339-48.
10 Shaffer D, Craft L. Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 1999; 60(Suppl 2): 70-4; discussion 75-6, 113-6.
11 Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital Statistics Report. DHHS Publication No. (PHS) 99-1120. Hyattsville: National Center for Health Statistics, 1999; 47(19). See also www.cdc.gov/ncipc/osp/states/10lc97.htm.
12 Brent DA, Perper JA, Allman CJ, et al. The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study. Journal of the American Medical Association, 1991; 266(21): 2989-95.
13 Fleming JE, Offord DR. Epidemiology of childhood depressive disorders: a critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 1990; 29(4): 571-80.
14 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.
15 Kovacs M, Feinberg TL, Crouse-Novak MA, et al. Depressive disorders in childhood. I. A longitudinal prospective study of characteristics and recovery. Archives of General Psychiatry, 1984; 41(3): 229-37.
16 Lewinsohn PM, Clarke GN, Seeley JR, et al. Major depression in community adolescents: age at onset, episode duration, and time to recurrence. Journal of the American Academy of Child and Adolescent Psychiatry, 1994; 33(6): 809-18.
17 Klein DN, Schwartz JE, Rose S, et al. Five-year course and outcome of dysthymic disorder: a prospective, naturalistic follow-up study. American Journal of Psychiatry, 2000; 157(6): 931-9.
18 Children's Depression Inventory. Developed by Kovacs M. Available from Multi-Health Systems (MHS, Inc.), 65 Overlea Blvd., Suite 10,Toronto, Ontario M4H1P1 Canada; phone: 800-456-3003.
19 Beck Depression Inventory. Developed by Beck A. Available from Psychological Corporation, 555 Academic Court, San Antonio, TX 78204; phone: 210-299-1061.
20 Center for Epidemiologic Studies Depression Scale. Developed by NIMH. Available from NIMH, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663; phone: 301-443-4513.
21 Harrington R, Rutter M, Weissman MM, et al. Psychiatric disorders in the relatives of depressed probands. I. Comparison of prepubertal, adolescent and early adult onset cases. Journal of Affective Disorders, 1997; 42(1): 9-22.
22 Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clinical Psychology Review, 1998; 18(7): 765-94.
23 Wells VE, Deykin EY, Klerman GL. Risk factors for depression in adolescence. Psychiatric Development, 1985; 3(1):83-108.
24 Monroe SM, Rohde P, Seeley JR, et al. Life events and depression in adolescence: relationship loss as a prospective risk factor for first onset of major depressive disorder. Journal of Abnormal Psychology, 1999; 108(4): 606-14.
25 Spencer T, Biederman J, Wilens T. Attention-deficit/hyperactivity disorder and comorbidity. Pediatric Clinics of North America, 1999; 46(5): 915-27, vii.
26 Brown J, Cohen P, Johnson JG, et al. Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. Journal of the American Academy of Child and Adolescent Psychiatry, 1999; 38(12): 1490-6.
27 Krug EG, Kresnow M, Peddicord JP, et al. Suicide after natural disasters. New England Journal of Medicine, 1998; 338(6): 373-8.
28 Jayson D, Wood A, Kroll L, et al. Which depressed patients respond to cognitive-behavioral treatment? Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37(1): 35-9.
29 Reinecke MA, Ryan NE, DuBois DL. Cognitive-behavioral therapy of depression and depressive symptoms during adolescence: a review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37(1): 26-34.
30 Brent DA, Holder D, Kolko D, et al. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry, 1997; 54(9): 877-85.
31 Mufson L, Weissman MM, Moreau D, et al. Efficacy of interpersonal psychotherapy for depressed adolescents. Archives of General Psychiatry, 1999; 56(6): 573-9.
32 Depression Guideline Panel. Clinical practice guideline, number 5. Depression in primary care: volume 2. Treatment of major depression. AHCPR Publication No. 93-0551. Rockville: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, 1993.
33 Emslie GJ, Rush AJ, Weinberg WA, et al. A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, 1997; 54(11): 1031-7.
34 Keller M. Paroxetine and imipramine in the treatment of adolescent depression. Presented at the 151st Annual Meeting of the American Psychiatric Association, Toronto, June 1998.
35 Geller B, Cooper TB, Graham DL, et al. Pharmacokinetically designed double-blind placebo-controlled study of nortriptyline in 6- to 12-year-olds with major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 1992; 31(1): 34-44.
36 Geller B, Reising D, Leonard HL, et al. Critical review of tricyclic antidepressant use in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 1999; 38(5): 513-6.
37 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.
38 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.
39 Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999; 45(4): 444-50.
Institute of Mental Health