Adolescent Depression

Adolescent is characterized by atypical irritability, depressed mood, or loss of pleasure in previously enjoyed activities lasting most of the day for at least two weeks; decreased level of school, social, or job functioning will also be observable. At least five of the following symptoms must be present as well: changes in sleep patterns or amount; weight changes (significant loss or gain due to changed appetite); increased or decreased activity level; fatigue or significantly decreased energy; feelings of guilt, worthlessness, or hopelessness; decreased attention, concentration, and decision-making skills; and suicidal thoughts or plans.

Symptoms, signs, and diagnosis

Depression is a worldwide phenomenon. It is estimated that between 10 and 25% of all adolescents will experience symptoms consistent with depression at some point. Of those, roughly 10% will have one episode or more during adolescence that is severe enough to warrant treatment. The depressive symptoms must be out of character for the adolescent's typical functioning, must cause significant distress or impairment in everyday life, and cannot be attributable to another cause, such as substance abuse, medical illness, or other mental illness. Depression tends to be episodic, recurring periodically across the lifespan.

Incidence of depression increases significantly after puberty and continues to rise throughout adolescence. It is much more prevalent in females than males. The most commonly listed predisposing, or sensitizing, factors for the development of adolescent depression are family history of depression; other mood disorders or severe, chronic mental illness; and exposure to extraordinary psychosocial stress.

Because adolescence is characterized as a time of rapid change, frequent mood fluctuation, increased irritability, and pulling away from family or other previous social supports, frank depression is often either overlooked or misdiagnosed. Adolescent depression may present with initial symptoms that are unlike those occurring in adulthood, such as school refusal, decreased academic performance, disordered eating behavior, anxiety, alcohol or drug abuse, behavior changes, or vague physical symptoms. Accurate diagnosis at onset may be difficult.

Treatment

There is a variety of possible treatments for adolescent depression. Options depend on patient age; type and severity of symptoms; number of previous depressive episodes; frequency of recurrence; whether or not suicidal thoughts, plans, or attempts are a current concern; level of interference with activities of daily living; severity of depression; environmental concerns such as family supports, stability of living situation, or exposure to significant stressors (such as domestic violence or substance abuse); previous treatment outcomes; and motivation for treatment by adolescent and family, or other support system.

There has been a great deal of research on the most effective (showing the best long-term outcome results) forms of psychotherapy for treatment of adolescent depression. For the mildest forms of depression, individual psychotherapy alone or in conjunction with psychosocial interventions such as group or family therapy; training in improved social and coping skills; education about depression and mood disorders; art or music therapies; or adjunct activities such as such as yoga, meditation, guided imagery, systematic relaxation, physical exercise regimens, and nutritional counseling have been proven effective. Among the individual psychotherapies, the results of a large body of clinical research indicate that cognitive behavior therapy (CBT) alone, which teaches the adolescent how to replace negative thinking patterns with positive ones, achieved the most promising results in mild depression.

In recurrent or moderate-to-severe depression, medication in conjunction with psychotherapy has been shown most effective. In very severe or treatment-resistant depression, particularly if accompanied by psychotic features such as thinking problems, hallucinations, or delusions, brief hospitalization to achieve stabilization and safety may be necessary.

Adolescents with clinical depression often have too little of the neurotransmitter serotonin circulating in their central nervous systems. As a result, they may be prescribed selective serotonin reuptake inhibitors (SSRIs). Prozac (fluoxetine) and Lexapro (escitalopram) are SSRIs that the Food and Drug Administration has approved specifically for use in the treatment of adolescent depression. Most of the antidepressant drugs used to treat adults have not been shown, in randomized clinical treatment research, to be effective in adolescents. The SSRIs carry increased risk of suicidal thoughts for some patients, and adolescents taking them must be very closely monitored.

Cognitive behavior therapy (CBT), an effective form of psychotherapy for many adolescents with depression, assesses the interactions between thoughts, feelings, and behaviors. It closely examines the thinking patterns that lead to negative self-talk and negative beliefs about self, resulting in destructive or self-harmful behaviors. In CBT, the patient and therapist work as partners in recovery. It is a solution-focused and goaldirected type of therapy.

See also Adolescence ; Adolescent Psychiatry; Cognitive Behavior Therapy; Depression .

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing, 2013.

Essau, Cecilia. Treatments for Adolescent Depression: Theory and Practice. Oxford, UK: Oxford University Press, 2009.

Gotlib, Ian H., and Constance L. Hammen. Handbook of Depression. New York: Guilford Press, 2009.

Huberty, Thomas J. Reed. Anxiety and Depression in Children and Adolescents: Assessment, Intervention, and Prevention. New York: Springer, 2012.

Rey, Joseph, and Boris Birmaher. Treating Child and Adolescent Depression. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams&Wilkins, 2009.

Springer, David W., Allen Rubin, and Christopher G. Beevers. Treatment of Depression in Adolescents and Adults. Hoboken, NJ: Wiley, 2011.

PERIODICALS

Reeves, G.M. and M.A. Riddle. “A Practical and Effective Primary Care Intervention for Treating Adolescent Depression.” Journal of the American Medical Association (JAMA) 312(8):797-798 (August 27, 2014).

Richardson, L.P., E. Ludman, E. McCauley, et al. “Collaborative Care for Adolescents with Depression in Primary Care: A Randomized Clinical Trial.” Journal of the American Medical Association (JAMA) 312(8):809-816 (August 27, 2014).

Wakefield, J. and M.F. Schmitz. “When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds.” World Psychiatry 12(1): 44-52 (February 2013).

WEBSITES

National Institute of Mental Health. “Depression in Children and Adolescents (Fact Sheet)” http://www.nimh.nih.gov/health/publications/depression-in-children-andadolescents/index.shtml (accessed October 8, 2014).

Substance Abuse and Mental Health Services Administration (SAMHSA). “Depression rates triple between the ages of 12 and 15 among adolescent girls” http://www.samhsa.gov/newsroom/advisories/1207241656.aspx (accessed October 8, 2014).