by Jim Chandler, MD, FRCPC
Most adults and many children and adolescents have a few bad days here and there, sometimes three or four in a row. When this happens, your mood is bad, you feel like jumping on people for nothing. You sleep, but you do not rest. You eat, but you are not hungry. Your life is one big chore. Everything that was fun is work and what usually is work is like walking with lead boots. Often you have stomach aches, headaches, aching, dizziness and other symptoms, but the doctors can not find anything wrong. When family and friends want to talk, you do not listen. If you can, you stay alone and wish they would all just go away. And you think about what you have got to do, and you wish you could put it off for ever. And about what you have done, and about what could go wrong, and how you could never live like this for 30 more years.
Of course not everyone has all those symptoms every time. When people are clinically depressed, they have this for weeks, months, and often years. Nearly everyone knows someone who has been severely depressed as 6% of the world's population has had an episode of severe depression like this. Some people know someone who has killed themselves because of depression. Suicide occurs in 15% of depressed people.
A lot less is known about depression in children and adolescents. Depression in children is very similar to depression in adults with a few exceptions. Rather than having a depressed mood, children are much more like to have an irritable mood. Adults often will not enjoy anything when they are depressed, but there are usually some activities children and adolescents will enjoy doing no matter how depressed they get. To say a child has clinically significant depression (Major Depressive Disorder or MDD), they must have five of the 9 symptoms listed below to such a degree that it significantly interferes with their functioning for at least two weeks straight.
Although it is not one of the criteria, some physical symptoms are very, very common in depression. Headaches are one of these. About 10% of children have severe headaches at least once a month. However 40% of girls with depression have severe headaches. The same does not hold true for boys. (8)
In this type of depression a child with no other psychiatric problems suddenly becomes depressed, sometimes for little or no reason. Sometimes their sleep is disturbed. They are not hungry, have no energy, are afraid of all sorts of things, think life is hopeless, can not concentrate at all, are less social and are very irritable.
Adolescents with depression are more likely to have the following features than children:
More Fatigue and sleeping too much
Suicidal thinking and suicidal attempts
Children with depression are more likely than adolescents to have:
Something that set off their depression
Comorbid ADHD or Separation Anxiety Disorder
Comorbid ODD (oppostitional defiant disorder) (48)
Sara is 5. She has been in preschool all fall and overall, she enjoys it and does fairly well. After Thanksgiving, she seemed to become less and less excited about pre-school. She thought the others were bugging her. She didn't want to go some days, but her parents made her. At home, it was the same. Nothing was right. When bedtime came, she couldn't sleep and wanted to sleep with her mom. She lost interest in playing with her cousin. She didn't get even get that excited about Christmas. She started telling her parents, "You don't like me". When they took her out to MacDonalds, she liked it, but she was never enthusiastic like she used to be. Her mother would notice her sitting in a chair with a horrible look on her face doing nothing.
Ryan is 11. He is in 4th grade and has always been an average student. Of their three children, he gave his parents the least cause for concern until these last few months. It started with him calling home from school to talk with his mom or dad. He just wanted to tell them what was going on. It was never good. He was worrying about passing, even though he was doing fine. Then he started saying that he just couldn't do the work. When his parents would ask why, he would just get mad and tell them they didn't understand. He refused to play hockey in the winter. He wouldn't go hunting with his Dad. The only thing he did was go to scouts and watch TV. So his parents decided to start restricting the TV. Ryan told them that if he couldn't watch TV, he might as well just die. They didn't take it seriously. He was sleeping all day, eating constantly and failing in school. His friends no longer came around. One day his father went to use the bathroom and didn't realize Ryan was in there. He wasn't using the toilet. He had a bunch of pills poured out on the sink.
Tessa is 15. When she was 13, her parents remembered her being a little irritable and to herself, but it was nothing like it is now. Whenever they say anything to her, she returns it with some nasty comment. It is very hard to live with. Tessa has stopped going out very much. She sits in her room with the door locked and listens to music. Sometimes she slams things around in there. Before, Tessa would usually be asleep by at the latest. Now she is up later than her parents. Sometimes her mother will come in and ask her if something is bothering her. "What's bothering me?" "Do you really want to know?" Yes, her mother did. So Tessa told her. Tessa felt she was the dumbest, ugliest, most useless piece of crap that God had ever made. She hated herself, her family, and her friends. She told her mother she just wished she could die and then starting crying for about an hour while her mother held her.
This is a milder depression that goes on for years at a time. Children and adolescents with Dysthymia often have been depressed so long that they can not recall what not being depressed is like. People think it is part of their personality. Typically they are irritable, hard to please, unhappy with nearly everything and very trying to be around. They tend to have fewer problems with sleep and appetite than children with major depression. To have this disorder you must be depressed or irritable for at least a year straight with at least two of the following:
Children with dysthymia often can still enjoy some activities. Children with dysthymia are at a very high risk to get MDD. Over 70% of dysthymia children will get severely depressed, and 12% will get manic depressive disorder. Rather than recover, they often go back to their dysthymic selves. A long episode of Dysthymia will screw up a child's life far more than a brief episode of severe depression.
Daryl is 9. He spends a fair amount of time thinking about the good old days. For him, this was when he was in grade primary and grade 1. Then life was fun. School was easy, there was nothing to worry about and he was happy. He goes for walks and wishes he was in grade 1 again. Now life is not to good. School is hard for him. Many days he tells the teacher that he just can't do the work. His teacher encourages him to try and lots of time he can, but he is very tense the whole time. One night out of the blue he asked his mom what it was like to be 35 years old. She said it was pretty good. Daryl couldn't imagine living that long. "You know, mom, I don't think I can live that long. Life is so hard and there is so much work." His mother was so stunned she forgot to remind him to eat his dinner.
Yvette is 16. She saw a school counselor and the counselor asked how long she had been feeling blue. Yvette looked at the calendar. "Only 16 years, 4 months, and 14 days", she said. Yvette could never remember feeling happy for more than a few days at a time in her whole life. Not that you would usually notice it. At school she did her work, had some friends, and participated in the church youth group. She tried very hard to make her face look like the other's. At home, she let down her guard. She was usually exhausted. She could come home from school and sleep two hours and go to bed at and sleep all night. If her parents let her, she would just sit in her room and read to try and not think about everything. The main thing she thought about was what could she do to make herself really happy? She had decided that if she could just find the right guy, maybe she would be happy. Sure, she thought, but who would want a dirtball like me?
This means the child has had dysthymia and now has an episode of Major Depressive Disorder on top of that. Outside of bipolar disorder, this may be the most serious type of depression. Compared to children with only Major Depressive Disorder or only Dysthymia, children with double Depression are sicker. They have more problems at home and more problems at school. They are less able to get along with other children. (30) As these children get older they have more suicidal thoughts and by the time they are adults, they are more severely ill than any other group of depressed patients. (31)
Jesse is now 12 and in 6th grade. She admits that this is the worst she has ever felt in her life. Since Christmas, her mom can not ask her to do the smallest thing with out screaming and sometimes swearing. When her mom asked ,"what's the matter?" Jesse stomps into her room, slams the door, throws herself on the bed and cries. What is the matter? She tells her friends that she hates herself. She hates her fat face. She hates her school. She hates the teachers. She hates her brothers. What is keeping her going? Not much, as she dropped out of youth group at church, quit girl's basketball, and won’t go to Girl Guides. What keeps her going is that she is afraid to kill herself because she doesn’t want to go to Hell and because she wouldn’t want to hurt her Grandpa.
She is worse now than when she was younger, but really she has not been well since she was about 7-8 according to her mom. Outside of birthdays and Christmas, Jessica has not been a happy child. She is usually down on herself and has always had a hard time keeping friends because she is so unenthusiastic. But now that Jesse's mom has found her book of poems, she wishes she had brought her in for help years ago. Sadly, this child, now 12, has been depressed for almost half her life.
Chantelle is 16 and is now failing 10th grade for the second time. Last year she has to admit it was because she was just lazy. This year she is really trying but she can't do it. She can't pay attention in school. She tries to do her homework but she can not get herself going. And now all she can think about over and over is that she is so stupid and it is really hopeless to even try. The guidance counselor says she can still pass, but Chantelle figures he is just saying that to be nice. So she stays at home, eats, and does nothing. "My weight goes up, my grades go down, and nobody ever wants me around" she writes on the chat lines. Her mom has been trying to convince Chantelle to get some help for years. She keeps telling her husband, "I want my daughter back". The daughter who was fun, liked to go out, had hobbies, and was not constantly giving up. This has been going on for about two years. One day her friend calls to tell her that she hope Chantelle doesn’t take it personally, but she is going to start going out with the guy who dumped Chantelle. Chantelle takes it personally. Chantelle takes 200 tylenol tablets. By coincidence her mom had a headache, found the bottle in the garbage and her daughter, nearly dead, on the floor.
Garison is now 11. He was depressed at age 4, according to his mother. She says she should know, as she remembers what it was like to be depressed as a little kid. She recalled wishing she was dead when she went to grade one. For a few years she just tried to deny it, then she just hoped it would go away. Then when he was in fourth grade he started saying things she used to when she was depressed. Then his grades went downhill, all he wanted to do was play video games, and he started to cry at night because he was afraid of dying. Then last year he started crying in school and was getting teased. She had had enough. She took him to her doctor and told him, "Garrison has exactly what I had. I do not want my son to go through what I did and suffer 20 years before he was treated". Well, Garrison started on the same medication his mom took. It made him vomit. They tried another and after a few months they had a child they didn’t really even recognize. Garison says the blackness is gone from his mind. Now his mom just wishes she had done something even earlier!
Some children will develop signs of psychosis along with their depression. A child might have hallucinations. The child might be very paranoid. The child might develop all sorts of bizarre and unusual ideas. This is the most serious type of depression. It is also quite uncommon.
Shelly is 14. Since Christmas she has not been herself. She knows she is no good. She tells her parents that everyone hates her and says bad things about her. They call her all sorts of obscene things and she doesn't want to go to school any more. She wants to just get away from them forever. At home she just eats, sleeps, listens to music and occasionally irritates her sister. So her mom decided to go to school and see what was going on. Amazingly, no one had noticed any teasing, but they had noticed that Shelly was much more withdrawn and inattentive in school. The next day she was able to get Shelly to come with her and go shopping. As they went in mall, Shelly was telling her mom, "Do you see what I mean? Listen to those two girls over there." Shelly couldn't stand it more than a few minutes. She pointed out to her mother a couple groups of kids who were saying bad things about her and talking behind her back. She noticed that they had scratched "Shelly sucks" on the window. Shelly's mom did not see or hear any of this. Shelly's mom saw something far worse. She saw that her daughter was very, very ill.
Comorbidity means that certain disorders occur more often together than one would expect by chance. For example, diabeties and obesity. The concept of comorbidity is very important in psychiatry. It is very common that a person with depression will also have another childhood neuropsychiatric disorder.
In this situation, a child has a preexisting chronic psychiatric illness and then becomes depressed. The episode of depression occurs along with the other disorder so that the child actually shows signs of two or three psychiatric disorders at the same time. About 50% of children with depression also have conduct disorder or oppositional defiant disorder, 40% of children with depression have anxiety disorder, and 25% of children with depression have attention deficit disorder. Often the episode of depression will go away and leave the other psychiatric problem unchanged.
In this case, children have episodes of depression, some episodes of wellness, and also some episodes of mania, which is the opposite of depression. See the pamphlet on Bipolar disorder for more information on this. Click here
It has become clear in the last few years that some children have depression only in one season, usually winter. It starts to worsen in late October and reaches its peak in January. By March things are usually on the mend. This can be extremely disabling, as this is usually when the hardest school work is. Approximately 3-4% of school-age children have SAD. There are many studies to show that light boxes can help adults with this condition. There are also studies in which this technique is used in children. This usually means sitting in front of a specially made light box and doing something for about 30 minutes five times a week. These boxes are not hard to make or purchase. Unfortunately, children are sometimes not compliant with them. Another technique is a dawn stimulator, which is a light which gets steadily brighter, mimicing a spring or summer morning. (9)
About .3% (3 out of 1000) preschoolers, 1-2% of elementary school age children, and 3-4 % of Jr. high students have MDD. Another 3.3 % have dysthymia. About 3-4 % of children have seasonal affective disorder. Co-morbidty is a very important determining factor. In most studies, nearly all of the cases of pediatric depression also have another co-morbid diagnosis. This is in the same range as adults.
In many cases, it disappears. About 90 % of the time it is gone within one year. Sometimes it disappears without any treatment at all. That is the good news.
The bad news is that depression in children is recurrent. That is, even after a child recovers, he or she is much more likely to get depressed again. About 35 % will get again meet criteria for MDD within a year from recovering. By two years, half of the children who recovered will have had a recurrence of their depression. About 75% of children will have a recurrence of their depression within four years of their first episode. Each time depression recurs, it makes it that much more likely that it will recur again.
Children are more likely to have a their depression recur if they started having depression before age 14, if there is divorce at the time of the depression, or if one of the parents is also depressed at the same time. No one can predict exactly who will have another episode of depression and who will not. Some of the predictors for another episode of depression are: one parent has been clinically depressed, one parent has another psychiatric problem other than depression, and the child has other psychiatric disorders (like attention deficit disorder, learning disabilities, or anxiety disorders). If all three of these are present, it is almost certain that a teenager will develop another episode of depression over the next 4 years. If a child lives in a family with a lot of conflict, they are more likely to relapse.
If nothing is done, the picture can be quite bleak. Ten to fifteen years later, 7.7% will have committed suicide. They are five times more likely to attempt suicide (without dying). They are twice as likely to get another episode of depression. Only 37% will have made it to adulthood without getting depressed again. This makes depression one of the most serious medical problems that a teenager can have, and one of the most lethal. It also should encourage all of us to identify and treat teenagers with depression so that they do not end up as a statistic. (34)
It is hard to know if an episode of depression is the beginning of bipolar disorder or not. Bipolar disorder means episodes of mania (see the bipolar hand out on what that is) and depression, but the depression of bipolar disorder looks about the same as the depression of major depressive disorder. So in some cases a child might start out with an episode of major depressive disorder and then later (maybe years) develop mania. Depression is a big problem, but bipolar disorder can be an even greater disability for a child. So which children with MDD may really have the beginnings of bipolar disorder? Those who have a family history of bipolar disorder and those who have had an episode of MDD before puberty. (33)
Judi is now 16. When she was in 5th grade she got crabby after christmas and her parents thought it was just from the stress of the holidays. By valentines day it wasn’t any better and her marks were going down. She didn’t seem to enjoy piano anymore and was having a lot harder time getting to sleep. They figured March break would bring her around. Usually she would meet friends at the library, go to the dairy queen, and skate at the rink during breaks. The problem usually was trying to keep track of where she was as she seemed to think she was 21, not 11. Not this spring break. She stayed home, watched TV and made up enough excuses so that her friends gave up trying to get her to go out. On April fool's day she broke down crying after her mom found her diary all about how she wished she was dead. So she went to the doctor, and after some counseling and some medicine, was well by the beginning of 6th grade and by the next summer was free of psychiatrists, medications, and counseling. She felt fine for three years. Then after her grandma died and her best friend left her for a new boyfriend, she got very depressed just like she did when she was little. The family picked it up early this time and everyone was confident that things would go quite smooth. She went on her medicine and 2 days later was feeling better than ever. Two days after that she was actually dancing on the furniture and telling incredibly dirty jokes at school and at youth group. A few days later she got made and threw a rock through the living room window and ran off. Her dad found her with her top half ripped flirting with a guy twice her age in front of the liquor store and brought her to hospital.
Judi started out with a typical episode of depression, then got another episode of depression that cycled into mania due in part to the antidepressants.
This is one of the "labels" psychiatry uses to describe people who have traits in their personality that cause them major problems. These are not things that come and go but last for decades. A person's personality starts to form as a teenager, and that is when we see personality disorders start to form. We have all met people with these types of problems. They fit into a few big categories that have lots of different names.
One group is people who are strange, different, and keep to themselves. Another group is people who are dramatic, have lots of mood problems, are forever getting into trouble, and whose lives are quite mixed up. They are often very difficult to get along with over the long run. Another group are people who are withdrawn, scared, and have to do things a certain way. When any of these problems screw up people's relationships, ability to work, get them in trouble with the law, or make them miserable, we call it a personality disorder. Why is this important? If you have another psychiatric problem along with a personality disorder, it is a lot harder to get better. Having a difficult personality as an adult is a heavy burden to bear. There are no great ways to change a personality once it develops. The presence of a personality disorder makes any other disorder harder to treat. A person with depression and a personality disorder is less likely to get better than a person who just has depression.
Recent studies have shown that children who have certain psychiatric problems are much more likely to get personality disorders as adults. Children who have multiple psychiatric problems are even more at risk. Children who have Depression are 3-8 times more likely to have a personality disorder when they grow up, that is between 1/4 and 1/2 will have personality disorders as adults. What this tells us is that the longer these problems go on in childhood and as teenagers, the more likely they are to lead to personality disorders as adults. (23).
Depression in children is caused by a combination of three things: genetics, what is happening in a person's life, and what is going on in their body. Usually, more than one is present in a child. For a child to get depressed, there must either be major things wrong with their lives, something major wrong with their body and or mind, or a strong family history of depression. Often more than one is present.
Medical problems-children who have chronic medical problems are much more likely to get depression. Severe asthma, severe head injury, diabetes, epilepsy, and many of the less common chronic childhood diseases can result in depression.
Neuropsychiatric - Children with certain disorders of the brain often get depression because the same chemicals and the same nerve pathways are involved in both. Children with the following neuropsychiatric illness are more likely to get depression: Attention deficit hyperactivity disorder, Learning disabilities, tourettes, Anxiety disorders, Eating disorders, Obsessive compulsive disorder, and autism and related conditions.
Environment- Some children, but not all, react to problems in their environment with depressive signs and symptoms. Common causes are abuse of all kinds, families that are in chaos, neglect, poverty, no consistent parent, school, or home, and horrible things like witnessing deaths, finding bodies, losing parents, etc. Although children who get depressed are more likely to have a stressful life event happen to them in the year before they get ill, the more important relationship is for children who have multiple stressful events. In a recent study, 50% of depressed children and adolescents had two or more major stressors in the year before getting depressed. In children without depression, no child had two or more major stressors in the past year. (12) There is an interaction between environment and genes. If bad things happen to a child and there is a family history of depression, a depressed child is a very likely outcome.
Television - Children who are watching a lot of TV are more likely to have a host of different psychiatric symptoms. Recent studies have shown kids who are watching over 6 hours a day have more problems with depression, anxiety, and aggression. (11)
Drugs and Alcohol - Substance abuse is very common, especially alcohol and marijuana. About 14% of teenagers test positive for street drugs on a urine drug screen when they come to their family doctor. Almost all of this is marijuana. (13) Just as with adults, a child can develop all the signs of depression due to drugs and alcohol use. However, recent research has found that it is more common that a child will become depressed and then start using drugs or alcohol rather than the other way around. In adults, when people stop drinking or using drugs, their depression usually clears over the next two to four weeks. In children and adolescents, this rarely happens. Even after they are clean, most depressed children and adolescents are still depressed.
Cigarette Smoking - It has long been thought that children and adolescents get depressed and then take up smoking. However the most recent data suggests that children who are smoking and are not depressed are four times more likely to become depressed over the next year than children who never smoke. (35)Will reducing smoking decrease depression? That is not as clear.
Depression runs in families (14)
If one of the parents has depression, about 40% of the children will get depressed at sometime before their 20th birthday. The younger the parent was when he or she got depressed, the more likely the children are to become depressed. When mothers have been seriously depressed (an episode every year or so and hospitalized at least once for depression) their children are even more likely to become depressed, and when they do it is more severe, last longer, and is accompanied by other psychiatric problems, too. These children also are more likely to commit suicide.
Why does depression run in families?
Even if a child never has contact with a parent, if that parent was depressed, it means that the children are also more likely to get depressed, too.
Depression in adults goes hand in hand with marital problems. The combination of divorce plus depression in parents makes it much more likely that the children will get depressed.
It is darn hard to be a good parent when you are depressed, and it can be pretty depressing trying to parent a depressed child. Parenting problems, whether they come from the parent or the child, can make everyone's depression worse.
Not all children of depressed parents get depression
That's right, common as depression is, many children don’t get depressed even when depression runs in their families or bad things happen to them or they get sick. What helps protect these children from depression? See the section on Prevention in the next section.
In medicine, a diagnosis is based on the history (talking with a patient and their families), a physical examination, and lab tests.
In adults, it is often possible to get by with only talking with the patient. This is never possible with children and adolescents. Children often will not say they are depressed. They are most likely to blame all their problems on school, friends, or family. Only by talking with the family can you get an outside perspective. On the other hand, children are better reporters than their parents of their own feelings. You need to check for all sorts of other possible psychiatric disorders and other medical disorders, too.
In children and adolescents, this may mean a large variety of things, depending on the history. Besides doing parts of the physical and neurological exam, a careful assessment involves observing how the child behaves, does school work, and gets along with his or her family.
This depends on the history, the exam and age of the child. Sometimes, no tests are necessary. Common things that end up being checked are thyroid tests, urine drug screens, tests for medical conditions that can mimic depression (infectious mono, for example), and other routine lab tests.
If you have diabetes, one of the ways that a doctor can tell that you are better is to check your blood sugar. It would be nice if there was a blood test to measure depression, but there isn't. The best way to measure depression is with a rating scale. This is a series of questions about the child which are answered by the doctor, patient, and family. This generates a total score. The score tells the family and me how severe the depression is. This can be very helpful in determining how much better a child is after a trial of psychotherapy or medications, or both.
Why should you treat Depression, since most people recover from it spontaneously?
If your child's depression resolves on its own, you are right. But, if it goes on very long or recurs, that means that your child is more likely to get an episode of severe depression or chronic depression. The longer depression goes on, the harder it is to treat. The longer it goes on, the more it damages the social, academic, psychological maturation of your child. Depression is a horrible problem in children and adolescents. The only thing more horrible is doing nothing about it.
Depression in Children and adolescents is hard to treat. In fact, as time goes by, the treatments seem to be less effective! Ten years ago psychotherapy looked like it was going to be a great treatment for depression in children. In the most recent studies, it was actually less effective than placebo! (53) Medications also were thought to be very effective years ago, but now it is known that they often don’t work completely, either. In a recent study of over 400 adolescents who were moderately to severely ill,
71% responded to psychotherapy plus medication
61% responded to just medication
43% responded to just psychotherapy
35% responded to placebo alone.(46)
Given these results, the best approach to depression in adolescents is to pick the treatment based on how severely ill the child is balanced with the risk, cost, and convience of the treatment.
The best studied psychotherapy is called Cognitive-Behavioral Therapy(CBT). None of the other types of psychotherapy have been studied anywhere near as much as CBT. (1) CBT is also used for anxiety disorders in children and anxiety and depression in adults. There are two parts of this treatment. One part concentrates on getting the person who is depressed to do things which will help their depression. The other part is to work on getting them to think differently. Here is a brief overview of what this means.
Cognitive-Behavioral Therapy that follows a manual or workbook has been found to be more effective than placebo in studies of mildly to moderately ill children. The question is, what about therapy that doesn’t follow a manual or workbook? To my knowledge, none of these have been found to be better than placebo in adolescents. .
What does manual based Cognitive-Behavioral Therapy look like? This is a link to some downloadable treatment manuals which give a good picture of what the therapy is like. (to Cognitive-Behavioral Therapy treatment manuals)
The big study noted above used about 15 sessions. A recent study using only 5 sessions found that adding this amount of psychotherapy to medication didn’t make much of a difference. (49)
If a normal child did everything a depressed child did, he would probably start to feel depressed, too. Depressed children and adolescents spend a lot of time doing dull and uninteresting things. Others spend most of their time doing nothing or being alone. The essence of this type of intervention is to get them doing more that is fun with others. What is fun? It depends on the person but the idea should incorporate one or two of the following: exercise, social contacts, and accomplishments. Usually there is some element of this type of intervention in every treatment plan. Often it is combined with the other types of treatment. Here are some ideas:
swimming at the YMCA with a friend or cousin
go to the beach with a friend
Go to a movie with a friend (not rent a video at your house)
get a model or craft you can do together
go for walks
go fishing, hunting, or biking with family or friend
go to a concert
go to a camp overnight
Have friends over
build something with friends
or join something like:
Church youth groups, sports teams like hockey, figure skating, baseball, soccer, basketball, volleyball and others, Computer clubs, Activities through the YMCA, art classes, dancing lessons, martial arts classes, the auxiliary of the Red Cross and RCMP, bands, choirs, Hunting clubs, Scouts, Girl guides, Some day care, School groups, swim team, beavers
These things will not be nearly as fun for the child as they would be if she was not depressed. However, they often will help children who are in a rut of depression, which leads to a more depressing lifestyle, which leads to more depression.
these interventions are easy to do
requires less motivation of the child than other interventions
no special skills needed
you don't need to be psychologically minded or a big talker
works well when other problems, especially ADHD, are present
requires a fair amount of parental time
doesn't always work as some depressed children and adolescents will refuse to do anything
Can cause conflict with brothers and sisters who feel the depressed child is getting special treatment.
Josh is 6 years old. Over the last two years he has become more depressed. He has slowly drifted away from his usual interests of soccer, legos and bike riding. What brought him to medical attention was that he was complaining that he didn't feel good in school and just wanted to go home. While home, he felt a little better, but not up to his usual. He was cranky and very little got him excited anymore. When he was seen, he spent most of his time indoors playing video games, watching TV, and just laying around.
The first step was to get him out and around. Since the thing that motivated him the most was nintendo, the new "deal" was that he could not play nintendo unless he went outside and did certain things. This included going for a bike ride with his brother and his brother's friends to the Dairy Queen, going to day camp, and taking swimming lessons. Josh didn't like the deal at all. His parents told him that if he didn't want to, fine, he could just sit outside and he would never see TV, much less, nintendo, again. It worked. Josh angrily complied and even though he didn't really want to enjoy these things, he started to. Within in a month he was much more active (with the "deal") and seemed to look a little better.
Tina is 11 years old. She is willing to go and do things, but she gets exhausted very quickly and wants to give up. This includes school, church school, Girl guides, and just playing outside. She has had a very big medical workup to find out the cause of her fatigue. When Tina started talking about how life just wasn't worth living like this and stopped eating regular meals, a psychiatrist got involved. Amongst other things, the Dr. wanted to get her doing more. Well, Tina said she just could not. They tried a program where each day she would go out for 5 minutes longer to play. Tina reluctantly complied as it was the only way she was going to get what she wanted, which was to talk to her friend on the phone in Alberta. They got Tina going to quite a few things, but they couldn't get her involved. After a few weeks, the family and the doctor gave up on this and put Tina on some medication.
Greg is 16. He has his license, a part time job, and he also goes to school. That was the way things were up until a few months ago. He lost his job due to an argument he was having with his boss. He started arguing with the teachers and got suspended for a few days. He was just as irritable and argumentative with his parents, and as a result he wasn't getting the car much. His girlfriend also decided that they she just "be friends". Greg's mom could see why. He was as cranky with his girlfriend as he was with his mom. So Greg spent a lot of time in his room playing electric guitar. The only thing he still did was go out to the movies on Fridays. One night, after a big scene over doing badly in school, he walked out of the house and told his mom that "he was history". Eventually the RCMP brought him to the hospital and that's how he saw the pediatric psychiatrist.
Part of getting him better was medications, but part was getting him out of the house. Since Greg hated the hospital, he was told there was a way to avoid that place. His Dad and Uncle took off some time to take him out and do things to get him out of his rut. Greg was so amazed by this that it actually helped.
Many depressed children spend a lot of time thinking very depressing things. For example, I am no good, too fat, ugly, dumb, unloved, clumsy, unpopular, etc. The idea is that anyone who spends a lot of time thinking like that will likely feel worse, not better. So, the essence of this is to try to teach people to not think like this. The first step is to get them to label these negative and automatic bad thoughts. The second step is to discuss and figure out better ways of thinking and problem solving than just running themselves down and giving up. The third step is to practice using these new thinking styles to solve problems in their own lives. This requires someone who is trained in CBT.
no side effects
Especially good for children and adolescents who are very verbal and want to "talk with someone"
The child needs to be adept with language and capable of analyzing their thoughts and feelings.
need to be quite motivated to get better
Need to find a therapist who has the time and expertise to do this.
Benjamin had been depressed since he was conceived, according to his parents. He saw the bad side of everything, felt that life was just too hard and was very irritable. He could see no good in himself. Besides having depression, Benjamin also has ODD. An irritable and oppositional child is no fun to have around or to be. Benjamin was quite smart and a good talker. The first step in this thinking or cognitive therapy with a child this age was to try and show him that all these negative thoughts could be changed. Most chronically depressed children don't think they can. The usual technique with children who can not think well on an abstract level is to take what is abstract (thoughts about feelings) and make it concrete. One technique which has been used in OCD and depression is to create a story about a good character (the child) and a bad character who is trying to put these negative thoughts in the good character. A common one is the "bad thought monster". Benjamin and the doctor talked about monsters, one of his interests, and his job was to go home that week and make a very large and very scary monster on paper. When he came back, we looked at it and then we decided that the fire it was breathing it would have some bad thoughts that he was shooting at Benjamin. The next week he and his folks were to come up with 10 bad thoughts that could be used as weapons against Benjamin. Benjamin had no problems coming up with these negative thoughts. The next step was to come up with "weapons" Benjamin could use against these bad thoughts from the monster. That took a little more work. Together they came up with some good reasons to think that these negative thoughts weren't true. With time, they planned to work on identifying the monster's bad thoughts and using the new defensive weapons to fight back. It all seemed kind of complicated, but he did eventually get better. Was it this type of therapy or not? No one really knew.
Personally, I have tried this with a few kids. I have not seen any child get markedly better, although others have reported it to work in this age group. It is certainly possible that I am just not that good at it.
Becky is 11. She got to see a psychiatrist when she told her parents one day that she was just tired of living and felt like walking away and dying. "Why?" her amazed father asked. Because I am no good to anyone was the answer. Besides no self esteem, she had also lost interest in dance class, her friends, and going to her grandmother's house. Mostly she stayed around home, complained of a headache, and watched TV.
The initial therapy was behavioral. Becky started getting out, even though she did not want to. This helped to a certain extent, but only a little. Since she was already keeping a diary and her mother was very keen to avoid medications, we decided to try a cognitive approach, too.
The first step was to have Becky write down some reasons she was depressed. The next step was to see if these reasons made sense. For example, one was " I depressed because I am stupid". When she talked about why she was stupid, it was because she was making mistakes in class and at dance class. With time, we went through all of her reasons and came up with some alternative reasons why these maybe weren't accurate statements about her. Some of the time it seemed to click. Other times it didn't. What really worked was having her keep a log of what she was doing, thinking, and feeling when she felt especially bad. It turned out that a few things were going through her mind a lot. Becky often sat and watched TV, thought about how bad her life was compared to other kids, and got depressed. Working together, we came up with some solutions to this. The first was shutting off the TV. This helped and gave her the confidence to continue with the treatment. Becky eventually recovered and she was very proud that she did it without medications. Her mom was also very proud.
Danielle is 15. Her life has not been easy. She has a learning disability in math, she was sexually assaulted for a couple of years by a teenager when she was 10, and she is depressed. Her family doctor put her on some pills for sleep. The bottle said not to mix with alcohol. After her parents were asleep, Danielle went downstairs, got the pills, and drank half a bottle of her parents wine. Her parents discovered her unconscious a few hours later. After a brief hospitalization, she was at home. The doctor decided to try a non-medical treatment as both parents were understandably terrified of psychiatric medications after the over dose.
So Danielle and the doctor met to talk about what this type of therapy might involve. They discussed how sometimes monitoring feelings, keeping a diary, and looking at the reasons why a person feels depressed can be helpful. Danielle seemed somewhat willing to try. Amongst other interventions to deal with her suicidality, her first assignment was write about what things made her feel like killing her self. She came back the next week and calmly told the doctor that if the doctor thought that this shit was going to make her better than he was even crazier than her. The doctor ended up abandoning this treatment. After a lot of discussion, she was readmitted, started on medications, and sent home with more behavioral type interventions along with the medications.
Note all treatments below this point which have been found to be better than placebo (the best test that something works) are in green font. Those that have not been tested or have not been found to be better than placebo are in red.
Like depression in adults, depression in children can respond to medications. These drugs make people sleep and eat better, give them more energy, lift their mood, and make it easier to not keep thinking the same depressing things over and over. These drugs are taken twice a day. They will take 4-10 weeks to show a full effect. They are all relatively expensive ($1.00-$4.00 a day). The doses are overall higher than adults as children break down these drugs faster.
While many drugs have been found to work for depression in adults, the same is not true in children. In fact, up until the last few years, no one had been able to show in a careful study that anti-depressants work better than placebos in children. Now there is clear evidence that the SRIs are effective in childhood depression. As a result, they are the first choice drug.
It is hard to predict which drug will work in a person. Sometimes if one drug in this family doesn't work, another will. The same is true for side effects. If a person has a lot of side effects from one drug in this family, they might tolerate another quite well.
These drugs don't usually work overnight. Occasionally a child is better in a week but usually it takes quite a bit longer. In fact, the most recent data suggests that the full effect of the drug may take 10 weeks or more to see. (22)You might not see any improvement for the first 3-4 weeks and then the child may start to gradually improve.
These drugs all increase the activity of the serotonin nervous system in the brain. These neurons are involved in the regulation of mood, appetite, sexuality, sleep, aggression, obsessions, and compulsions. The side effects are usually fairly minor, but of course some people will react strongly to them. The most common are restlessness, insomnia, weight loss, abdominal pain, decreased sex drive, and occasionally a rash. All of these are reversible upon stopping the medication. Very rarely, perhaps around one person in one thousand or less, children will get unusual movements from these medications. These may take awhile to disappear after the drug is stopped, but they do disappear.
There is one side effect that is not reversible usually on stopping the medication. That is induction of mania. In people who are susceptible to mania, sometimes these drugs will make them manic. This group is people who have had mania, have a strong family history manic-depressive disorder (now called bipolar disorder), or who have severe, long-standing depression. It usually appears over a matter of 2-3 days. There is a big change for the worse in the child. They can be bizarre, but usually are super hyper, aggressive, and totally out of control. It usually requires hospitalization and medication. All drugs for depression can do this. It is rare, but it does happen in about 5-8% of children. Sometimes children just become a little hyper and agitated on these drugs. This is another uncommon side effect that can look like mania, but it is much milder. If I am very worried that a child will become manic, I will start anti-manic medicine first. There is more information on Mania in the bipolar handout.
The drugs in this family can change how much of other medicines get into your blood stream. Other drugs can also change the amount of these SRI medications in your blood stream. What can happen? Here are the possibilities:
If you start taking a drug that interacts with the SRI, the amount of the SRI in your blood could go up enough to give you more severe side effects.
If you start taking a drug that interacts with the SRI, the amount of the SRI in your blood could go down and you could become more psychiatrically ill again.
The SRI can result in another medication going up in your system, too. If you were taking other drugs while you were on an SRI, those other drugs might give you more side effects.
Unfortunately, the SRIs are not similar in this regard. Each one has different medications that it interacts with.
Example: Tina has a cough
Tina is 11. She has been taking Prozac now for about a month and she is a lot better. But she has the flu which is going around and so her mom went to the drug store and got some cough syrup. Tina took the cough syrup and got very, very confused. Her mom (already nervous) was worried that Tina was getting meningitis. She took her to the hospital and was glad to find out that it was a drug interaction between dextromethorphan, the main ingredient in cough syrup, and Prozac. Still, it took Tina about a week to get over this. (27)
Safe in Overdose
Most people have few if any side effects
All side effects are reversible
require no special Monitoring
Work in 70% of cases.
Expensive up to $3.00-$4.00 a day
do not work immediately
do not usually help ADHD
The following drugs are in this family:
10, 20, liquid
Long acting, can be dissolved in water
20-60mg a day
10, 20, 30
Worse withdrawal symptoms, more weight gain
20-40mg a day
Capsules which can be dissolved in water
Pills are scored, can be ground up
10-20 mg a day
Related to Citalopram
Can help ADHD
This drug has been tested for ADHD in adults and children and Depression in adults. However since it is helpful for ADHD, it is a drug we consider when children have ADHD and depression.
This drug has been available in the
Rashes are not uncommon, about one out of 6 children can get one which usually resolves over 3-4 days. Nausea and vomiting can occur. About 1/3 of children will lose a little weight.
Less common side effects include irritability,
sleep problems, and head aches. It can cause seizures. This is most frequent in
over doses and when patients also have Bulimia. In adults, 4 out of 1000 people
will have a seizure using the short acting form of the drug. However, the long
acting form used in
Compared to the other non-stimulant drugs for
ADHD, the monitoring necessary is minimal. No ECGs
or blood tests are necessary. It can be helpful when depression is also
present. It has been used a lot in the
There has been some, but not a lot of research on this drug. It seems quite safe in adults, and it probably is in children. However, there is a possibility that something will come up which is a problem with this drug in the future.
This drug has been used for treatment resistant depression in adults, ADHD in adults, and some children with depression. It has not been found to be effective in children, but it is better than placebo in adolescents,(56).
It is very safe and requires minimal monitoring. The usual dose is about 1mg / lb. It can cause constipation, stomachache, a headache, and is occasionally sedating. It is quite expensive. The one study that was done which compared this to placebo showed that placebo worked just as well, but the dosages were very low, never more than 75 mg a day. (40) If a child has depression that has not responded to an SRI or Welbutrin, I would usually try this.
Mannerix, Remeron, tricyclics……
There is no data to support the use of these drugs for depression in children.
The sad truth is………….
There are only four drugs that have been found to be better than placebo for depression in children:
Why do SRIs work better for anxiety disorders in children than for depression?
No one knows, at least in 2007.
There have been a number of recent reports of antidepressants making people, especially teenagers and children, more suicidal, not less suicidal. This can happen!
Yet often times the combination of antidepressants and psychotherapy can prevent suicide.
Be aware that a person can become more suicidal. Usually this happens within the first 10 days of starting an antidepressant.
Every person who is starting antidepressants should be asked about suicidal ideas on a regular basis when the drug is being started.
If a person is becoming more angry, more irritable, and bad tempered, the medication should probably be stopped.
By taking this careful approach, the risk of antidepressant induced suicidal thinking and acts can be greatly reduced.
No drug works well if it not taken properly. This is a big problem with children who are taking medications for depression. The reason that children do not take prescribed medicines is different than the reason adults do not take them. For adults, side effects, not thinking they really need the drug and not thinking that it is going to work make non-compliance more likely. In children and adolescents, that is not the case. What makes teenagers refuse to take medication? Well, if they are refusing to do other things that are suggested and are abusing drugs, they are not likely to take medications properly. In children that have been discharged from hospital, only 40% are actually taking the medications as prescribed when they go home. (10) This always needs to be addressed before giving medications and when medications are not working.
Overall, once a child is well, it is best to continue with the medication at the full dose for a full year and then try tapering it off
Substance abuse needs to be treated. Even though they may still be depressed after stopping drugs or alcohol, they will certainly not improve if they continue to abuse.
If a child is so ill that they can not eat, are having hallucinations, or
are a serious suicide risk, this is an option. It is not a great option for
Just like adults, children can have a pattern where they get more depressed in the winter. Often it is hard to tell whether or not they really hate school, or whether it is the darkness, or both. There are many studies of using lights for seasonal affective disorder (winter depression) in adults. There is one study comparing light therapy to placebo. This showed that light therapy was effective. (43).
However, in my experience this sounds good, but practically is useless. This entails getting a child to sit in front of a light box at home for an hour a day, optimally in the morning before school. While it might be possible to do this with a well child, doing it with an irritable depressed child is not usually possible.
Even children who have responded to light therapy will refuse it after awhile. An alternative is dawn simulators. These plug into a lamp and the lamp slowly gets brighter at the same rate as a spring day. The child doesn’t have to get up earlier or do anything. This is much more practical. This probably works because the eye is very sensitive to this kind of a signal early in the morning. In the literature there is one case report of its effective use in children. 44) (Dawn Simulators are about 200 dollars US. There are many sources of them and if you search "Dawn Simulator" on the internet you will find them.)
I am now starting to use Dawn simulators in my practice, as they are the only practical light therapy in the severely ill children I see. Light therapy works within a week in most children. It does have a risk of mania similar to medications. It can also cause headaches.
For many people, the first choice for treating many conditions these days is herbs and vitamins. For years a number of preparations have been used for depression. The one that has been the best researched is St. John's Wort. A recent review of all the trials of this drug suggested that it was an effective treatment for mild to moderate depression in adults. It was better than placebo and often times as good as antidepressants. It was overall well tolerated. (18)
The question is, how about children and adolescents? There is one large study where 101 children under age 12 were given St. John's Wort. There were no severe side effects. The drug seemed to work great, but then it was not compared to a placebo, so it is hard to draw any conclusions from this since in the most recent study of the use of medications in childhood depression, 69% responded to placebo. (42)
My experience has been very disappointing with this.
Although many children I have seen have tried this, I have not had one child
have a sustained response to
Wort. This is probably because it is a fairly weak substance and depression in children is harder, not easier to treat than in adults.
It turns out that people who have low amounts of Omega-3 fatty acids and more other fatty acids have higher suicide rates and more depression. This led to people trying to give depressed persons Omega-3 fatty acids. While some come from grains, nuts and vegetables, most comes from wild, not aquaculture, fish. So to take supplements of this means taking fish oil, usually from Tuna, herring, or seals.
It is quite safe, but there is one problem. Whether it is a
liquid or a capsule, some people get indigestion from it and have a horrible
taste in the back of their mouths which we in
It has been used for some time for ADHD, but now there is better data to suggest that it may be much more helpful in depressed children.
There has only been one placebo double blind study of Omega-3 fatty acids in children and it was very, very positive. In the study, 7/10 children were at least 50% better while no one on placebo improved.
As a result of this, Omega-3 fatty acids are reasonable to try in children. While there is not a lot of data, they are very safe. The effect was seen within a few weeks and the children continued to improve out to 3 months. (52)
One of the most important treatments of psychiatrically ill children is to treat the psychiatric problems of the parents. The two most studied associations are depression in mothers and alcoholism in fathers.
If mothers are depressed, the children are also likely to become depressed. What is most important is that if you treat the mothers depression, the child’s depression is much more likely to improve also. Secondly, the child is more likely to stay better and not relapse.
If you treat children for depression and the mother’s stay depressed, only 12% of the children are better after three months.
On the other hand, of the mother’s get better from their depression, 33% of the children get better from their depression in 3 months. (51)
To be more clear-
Mia is 10 years old. She has a classic picture of depression, and having gone through the samething herself for years, Sally wanted to get her daughter checked out. Mia was very depressed and also anxious. Mom was focused on her daughter, not herself, but when we had her fill out the depression screening test, the score was very high. So Mia took meds and had counseling and mom went back on her meds. Six months later, both were well.
This is why the mother of everyone who comes to see me for depression gets to fill out a screening test for depression.
The aim of treatment is to get people well, not just better. Children and adults who get somewhat better, but do not get back to their “old self” are much more likely to relapse later. Many times if you continue aggressive treatment, children and adolescents will be more likely to recover fully. Getting people from better to well requires the same types of treatments as above (medications, Cognitive Behavioral therapy) but also relies on a few other “treatments” such as:
Getting a part time job
Joining an activity an excelling at it
Finding a best friend or two
How long does medication need to be taken?
There is only a little data to go on for children and adolescents. The best study showed that over a year’s time, 60% of children on Placebo relapsed, but only 34% on Prozac did.(47) There are many similar studies in adults. Here is what I do:
Everyone who ends up on medication should take it for at least a year.
If it took two or three medications to find one that really worked, I would have the child take it two years.
Similarly, if a child has been psychotic or had a severe suicide attempt, I would have them take it two years.
How do you go off the medication?
Slowly. This is called tapering. That leads to minimal withdrawal and less chance of relapse.
What happens if the child relapses after medication is stopped or during the taper?
Then they go back on the medication for at least two years, maybe more.
What about psychotherapy?
For the first episode of depression, it is adequate to stop psychotherapy once you are well. For treatment resistant depression and people who have relapsed after they get better, “booster sessions” are a good idea. This is monthly to every three month psychotherapy. When medication is being tapered down, it is also a good idea to go back to psychotherapy for awhile, especially if you have relapsed before.
If you have a child who is now depressed, it is quite likely that you have other children who may also be at risk. Brothers, sisters, and parents sometimes have many of the same risk factors. For example, the genetics may be the same if a brother has the same parents. Often the environment can also be very similar. It is a lot easier for a child to get better from depression if his sisters and brothers are not depressed. It is very hard for a child to get a lot better from depression if one or both of the parents are depressed. What can you do to prevent depression?
Children who have some very close relationships, value these relationships, and work to make sure they stay that way are in part protected from depression.
If a child is involved in school in every way they are more protected from depression.
The child who is really "into" sports, clubs, church, arts, etc. is less likely to get depressed.
If children and their parents know what depression is, what causes it and what can be done about it, they will go a long ways towards preventing it. These things that help protect children from depression are the backbone of preventing depression .
Most children who have depression and many adults who have depression are never identified because no one ever realizes that person is depressed. If you have read this far, you know what depression looks like. Do other children in your family have this? Do you? Does your spouse? Remember, depression runs in families! For example, if you look at people who are severely depressed at age 21, one quarter were already showing signs of depression at age 6 and over a third were showing sings of depression at age 9. (29)
At present, depression is a treatable disorder. There are medical and non-medical treatments that are effective. You and your children do not have to live with untreated depression.
Depression is often a recurring disorder in children and adolescents. Once the treatment of depression has finished and people are well, it is easy to forget about it and hope it won't occur. There is some evidence now that some strategies can help reduce recurrences. (See below)
If you have other children that have many of the same risk factors for depression, you should work on the doing things that may reduce their chances of ever getting depressed in the first place. See above section on Prevention.
It is usually possible to diagnosis depression based on a clinical exam, what the child tells you, rating scales, and what the parents/caregivers say. Based on that, sometimes I need to do certain tests or call the school, but not always. Figuring out what to do is based on a few things:
How severely ill is the child?
What else do they have?
How motivated are they to participate in non-medical treatment?
What have the parents/caregivers tried already?
How much do the child and parents/caregivers dislike the idea of medications?
How disabled is the child from this problem?
What other medical problems are present?
Jeanette is 14. She has been a little anxious all her life but not enough to cause her problems. Over the last 5 months she has become more and more irritable and now has a full MDD picture. She is also thinking about suicide, which got her in to see me. She does great in school. Her Children's Depression Rating Scale score is 47, which is in the moderate range.
She is not that ill, she has a lot of other strengths. I would try the non-medical approaches first for a few months. If she improved, then we would just use non-medical interventions. If she didn't improve, we would add medications. If she started to worsen during that time, I would add medications.
Jeanette still seems pretty depressed after 8 sessions of psychotherapy, but she isn't thinking about suicide. However, now here concentration is worse. Her Children's Depression Rating Scale score is now 30. After two months more of psychotherapy, the score is 25. This is in the normal range. As a result, Jeanette did not have to take medications.
Rob has always been pretty hyper and has been diagnosed with ADHD since age 7. Now he is 10 . He also has a reading disability. Over the last few months, he has become mildly depressed, but given the other problems he has, his self esteem is going through the floor and his irritability plus impulsiveness are getting him in big trouble. Rob's Dad has been treated for depression in the past. It took 10 years for him to seek treatment. One month after his father started medications for depression, he was a changed man. The Children's Depression Rating Scale score is 82, which is in the severe range.
His parents are keen to do something medically. Given his problems, I will start him on the same medication as his dad and try the environmental type treatments.
Rob says he is better, but his parents don't see much of a change. His Children's Depression Rating Scale score is still 40. Now Rob is going to psychotherapy, too.
After only a week, he started to improve. Now he is doing very well. His Children's Depression Rating Scale score is now 22. He will continue on the medication for a year.
Tanya has been depressed for two years. She made a serious overdose attempt. She is now in the hospital. Before getting depressed, she was anxious, in part because of being abused as a child. She is 15. Her Children's Depression Rating Scale score is 88.
Everything! Overall, if someone is this ill, you want to try everything at once and worry later about what caused her to get better. Many psychiatrists feel that the best long term outcome is when medical and non-medical treatments are combined. Tanya started Prozac 20mg a day and after a week it was increased to 40mg a day.
Tanya is not a big talker. There was a housefire since the last appointment and it is hard for her parents to remember how ill she was and if there was a difference or not. They missed a few psychotherapy appointments, so the therapist can't say either. A Children's Depression Rating Scale score is done and shows 33, suggesting she is better.
Stephanie was hypomanic for two weeks at age 11. Now she is 13 and is quite severely depressed. How did the family pick up the hypomania? Well, the mother had seen it in her father many times as he has bipolar disorder.
First do no harm! the chances of making Stephanie manic are at least 50%. First, she should be tried on non-medical treatments along with a mood stabilizer. Then, if that doesn't work, a antidepressant can be added. See Bipolar handout for details.