Major depressive disorder

Depression is a psychiatric disorder that afflicts young people with chronic feelings of sadness or worthlessness—the defining characteristic of the disorder is that it robs a person of the capacity for pleasure. Unhappiness is not uncommon in children, triggered by events—they get grounded, they get a bad grade, a friend betrays them—but it normally goes away when circumstances change. A child with depression doesn’t recover when events change; her dark mood and lack of interest in things she used to enjoy will persist.

 

Depression can interfere with all aspects of a child’s life, resulting in absences from school, trouble socializing with peers, and, in severe cases, thoughts of suicide. Young people with depression can have acute episodes that last weeks or months, or experience it less intensely over a longer period. Depression is diagnosed about twice as often in girls than in boys, though some think that its actual prevalence in boys may be underreported. Onset is usually in adolescence; some think it’s triggered by puberty.

The key sign of depression is a change in mood: unusual sadness and a reduced interest in activities—sports, friends, school—she had enjoyed. Anticipation of things she normally looks forward to is no longer pleasurable. Some depressed adolescents lose anticipatory pleasure but are able to enjoy what clinicians call “consumatory pleasure”—that is, the idea of pizza no longer interests them, they won’t seek an opportunity to get pizza, but served pizza, they can enjoy eating it. This presentation, known as atypical depression, can fool parents, who may dismiss their daughter’s dogged lack of interest as “acting” or just being oppositional.

 

Other signs of depression are unexpected, involuntary changes in weight; major shifts in sleep patterns; and sluggishness. Some experts believe excessive irritability is a major warning sign of depression in younger people, though that is a point of contention. A depressed child may be unusually harsh on herself—I’m ugly, I’m no good, nobody likes me. In the most extreme cases, depressed kids may have thoughts of or make attempts at suicide.

The causes of depression are myriad, interconnected, and still poorly understood by the scientific community. Abnormal brain function likely plays a role, and the disorder runs in families, indicating agenetic component. But most depressed people don’t have a family history, and not everyone at higher risk for depression will manifest the disorder—one clinician calls that genetic predisposition “a vulnerability, not a fateful sentence.”  Similarly, depression appears to be triggered by traumatic life events in some cases, but the vast majority of depressed kids haven’t suffered a trauma and do not come from abusive backgrounds.

In diagnosing depression, a professional will depend upon observations of a child by family members and other adults involved in her care, as well as her own descriptions of her life.

 

For a diagnosis of major depressive disorder, a young person will be in a depressed or irritable mood most of the time, or lose interest or pleasure in daily activities most of the time, or both, for a sustained period, in a distinct shift from previous functioning. In addition, she will show a variety of the following signs: marked weight loss or gain; sleeping too much or too little; restlessness or lethargy; fatigue; “feelings of worthlessness or excessive or inappropriate guilt”; cloudy or indecisive thinking; and a preoccupation with death, plans of suicide, or an actual suicide attempt. A clinician will also need to rule out other causes for these symptoms, including substance abuse, medical conditions like diabetes and hypothyroidism, and other psychiatric disorders. The condition must significantly interfere with her day-to-day activities.

Mild cases of depression are treatable with specialized psychotherapies alone, but experts agree that in most cases a combination of psychological and pharmacological therapies is the best approach. Here’s what you can expect:

 

Psychotherapeutic: Childhood and adolescent depression is often treated with interpersonal therapy, or IPT. In IPT, a therapist focuses on a youngster’s relationships with peers and family, and how they can positively (and negatively) impact the child’s the inner life. IPT for young people with depression also encourages kids to seek out and participate in the activities they’ve lost interest in with the goal of jumpstarting recovery, a process called behavioral activation.

 

Cognitive behavioral therapy (CBT), which seeks to treat psychiatric disorders by teaching children how their thoughts affect feelings and behaviors, has also been used to treat depression, but there are questions as to the effectiveness of that method.

 

Pharmacological: Many medications have proven effective in combating depression. A course of therapy usually begins with one of the reuptake inhibitors, medications that increase the supply of certain neurotransmitters—chemicals parts of the brain use to communicate with each other—a shortage of which has been associated with depression. These drugs include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and norepinephrine and dopamine reuptake inhibitors (NDRIs). These medications, while still having some significant side effects, are safe if properly managed.

 

The FDA has decided, based on research, that all antidepressants run the risk of encouraging suicidal thoughts, and they all carry warning labels. But the phenomenon is rare and has been tied only to suicidal ideation, not actual suicide attempts. Experts believe that the benefits of these medications for depression patients far outweigh the risks.

Depression is very often diagnosed alongside anxiety disorders like generalized anxiety disorder(GAD) and panic disorder. Depressed youngsters are also more at risk than the general population to develop alcohol and substance dependencies.

Suicide risk:

 

Children and adolescents with major depressive disorder are at increased risk of committing suicide—the third leading cause of death among adolescents and young adults aged 15 to 24. Never ignore signs of suicidal behavior or ideation, which include: drastic changes in eating habits, sleep patterns, or personality; marked neglect of personal appearance; giving away personal belongings; sudden happiness after a period of depressed mood; and, of course, talk of suicide or of “going away” or “not being a problem anymore.”

 

If you think your child or adolescent is suicidal, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 or 911 if there is an emergency. Don’t hesitate—the risk of suicide in children and adolescents is all too real.

Is it my fault?
While certain environmental factors—stress, trauma, tragedy—can trigger a depressive episode, experts agree that the underlying cause of childhood depression is not environmental. Though precipitating factors are likely necessary for depression to manifest, these same stressors will not result in depression unless a child is vulnerable.
Is it my kid’s fault?
No. The irritability, anger, and shifting moods in a depressed teenager can seem willful at times, but these symptoms are the manifestation of a real and painful psychiatric disorder the child can’t control. It’s no one’s fault.
Are antidepressant drugs safe?
Yes. The federal government requires that all antidepressants carry a label indicating that the medications can cause thoughts of suicide. But the incidence is low; suicidal thoughts are quite different from a suicide attempt; and the benefits of these drugs are well documented. Untreated depression is a greater risk to a teenager’s health and happiness.
Will my child outgrow depression?
Probably. It is possible for someone diagnosed with major depressive disorder to experience only one episode during her lifetime. But the suffering and dysfunction caused by mood disorders can harm a child’s development, academically and socially, making treatment a far better option than waiting. And young people with major depressive disorder are more likely than others to have it in adulthood.
How does it affect school?
Depressed kids often feel so burdened by the ordinary demands of life that they avoid them, and that includes school. They may not feel able to face the challenge, and may also avoid socializing with friends in the ways they did before their depression. With diagnosis and treatment, a child with depression can successfully participate in educational and social activities.
What is my role in treatment?
Therapy sessions are generally a one-on-one encounter between your child and her therapist, but the therapy does not end there—often, techniques your child learns in the office will be brought to bear at home, with your help. Likewise, interpersonal therapy needs your help to succeed, as your relationship with your child will often be the subject.
How long does treatment last?
It depends. Some cases of depression can be quickly alleviated by treatment, and never come back. On the other hand, some sufferers require extended intervention.