Depression in
Children and Adolescents- what it is and what to do about it.
by Jim Chandler, MD, FRCPC
What about children and adolescents?
Depression runs in families (14)
The four prong attack on depression
What is Depression?
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.
What about children and adolescents?
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.
- depressed or irritable mood most of the
day, nearly every day
- markedly diminished interest or pleasure
in all, or almost all activities most of the day, nearly every day
- significant weight loss when not dieting
or failure to make appropriate weight gains
- trouble sleeping or too much sleeping
nearly every day
- restlessness or really slowed down nearly
every day which is obvious to others
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive
guilt nearly every day
- diminished ability to think or
concentrate, or indecisiveness, nearly every day
- recurrent thoughts of death, suicidal
thoughts or suicide attempts
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)
Common
clinical pictures of depression in children
Pure depression (MDD)
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.
Depression in children doesn’t look
quite like depression in adolescents
Adolescents with depression
are more likely to have the following features than children:
More hopelessness
More Fatigue and sleeping too much
Weight loss
Suicidal thinking and suicidal attempts
Substance abuse
Children with depression
are more likely than adolescents to have:
Something that set off their depression
Comorbid ADHD or Separation Anxiety Disorder
Comorbid ODD (oppositional defiant disorder) (48)
Examples
4-7 years old
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.
7-12 years old
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.
13-17 years old
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 10:30 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.
Dysthymia -
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:
- poor appetite or overeating
- insomnia or excess sleeping
- low energy or fatigue
- low self esteem
- poor concentration or difficulty making
decisions
- feelings of hopelessness
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.
Examples
4-7 years old
Lynn's parents didn't
really notice anything unusual about her until they had another child when Lynn
was 2 years old. Now Lynn is 5 and Andrew is 3. Andrew gets excited about
stuff. He is enthusiastic about life. He is happy when he can do something new
and he is excited to tell everyone. Lynn, on the other hand, never gets that
excited about anything. If everything is going exactly her way, she is happy. the rest of the time, which is mostly, she is upset at
someone or something for ruining her day. Most things seem to be an effort for
her. She would spend endless hours watching TV if her mother let her. When
Andrew watches TV, he is sometimes interested or bored or scared. Lynn is just
vacant. Lynn is the same way with other children. Her parents hate to compare,
but Lynn is a hard child to love. She is so hard to please and so rarely upbeat
about anything.
8-12 years old
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.
13-17 years old
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 9:30 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?
Double Depression
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)
Examples
Jessica
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
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
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!
Psychotic Depression
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.
Example
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.
Comorbid depression-
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.
Bipolar depression-
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
Seasonal Affective
disorder(SAD)
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)
How common is Depression in children?
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.
What happens to depressed children?
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.
What
happens to depressed teenagers when they grow up?
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)
Bipolar
Disorder
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)
Example
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.
Personality Disorder
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).
Suicide
(There is a
separate handout on this Click to go to that)
What causes depression in children?
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?
Genetics
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.
Marital Difficulties
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.
Parenting problems
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.
Diagnosing
Depression
In medicine, a diagnosis is
based on the history (talking with a patient and their families), a physical
examination, and lab tests.
History
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.
Examination
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.
Lab tests
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.
Rating
Scales
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.
What can be done?
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.
Treatment choices
Watch and Wait
This means doing very little
except encouraging lifestyle changes that help depression: better diet, more
exercise, adequate sleep, getting out, and restricting video and computer
use. This works about 40% of the time
Advantages: convienent, no
risk, no cost
Disadvantages: Not the most
effective treatment
Psychotherapy
This is outlined below. It
means going to a very well trained counselor for about 10 times at least and
doing homework.
Advanatages: teaches helpful
skills to manage depression, no side effects
Disadvantages: costly, hard to
arrange, hard to comply with, not that effective on its own
Medication
This means using some of the
drugs used in adults for depression
Advantage: The most effective
single treatment, easy to start, convienent
Disadvantage: serious side effects,
including becoming more suicidal, are possible
Medication plus Psychotherapy
Advantage: probably the most effective
Disadvantage: Side effects, inconvienent, hard to comply with.
Matching
the treatment to the child.
Mildly-moderately ill children
who hate the idea of pills and counselors
Watch and
Wait treatment plus lifestyle changes
Moderately ill children who
won’t talk to anyone
Medications
alone plus lifestyle changes
Moderately ill children who
hate pills and can talk
Psychotherapy,
which includes lifestyle changes
Suicidal children
Medications,
psychotherapy, and Lifestyle changes, if they will agree.
Description of treatments
Watch
and Wait treatment with lifestyle changes
This is the common sense
treatment for depression. That is, if you do the following you will probably
improve:
Improve your nutrition
Do things that are fun
Get more exercise, preferably
outdoors in the day (54)
Stay off drugs and alcohol
Get enough sleep
Pay attention to your
spiritual side (55)
Cognitive-Behavioral
Therapy
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)
How much psychotherapy is enough?
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)
Basics of Cognitive-Behavioral Therapy
Environmental-Behavioral interventions
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.
The
good
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
The
bad
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.
Examples
of Behavioral Therapy in children
4-7
year olds
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.
7-12
year olds
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.
13-17
year olds
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.
Work on changing thinking and feeling (Cognitive
Therapy)
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.
The
good
no side effects
Especially good for children and
adolescents who are very verbal and want to "talk with someone"
The
bad
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.
Examples
4-7
year old
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.
7-12
year old
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.
13-17
year old
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.
Medical interventions
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.
SRIs
(Serotonin Reuptake Inhibitors)
Introduction
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.
How they work
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.
Getting Manic
from SRIs
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.
Drug Interactions
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. This does not mean that these drugs are dangerous. It
does mean that if you are taking a SRI, a doctor should make sure that it will
not interact badly with other drugs you might be prescribed. It also means you
should check with the pharmacist before you take anything. (28)
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)
Antidepressants and Suicide
There have been a number of
recent reports of antidepressants making people, especially teenagers and
children, more suicidal, not less suicidal. This can happen!
Can SRIs
cause Suicide?
About 8 years ago,
researchers looked at the studies of young people treated with SRIs, and it
looked like more of the children and adolescents who took SRIs thought about suicide
than those who didn’t take SRIs. There was no difference in actually trying to commit
suicide. After that warnings appeared about this in the patient information
handouts.
Now it seems that this is not really true. People who take SRIs are a lot less suicidal. The only difference in young people is that it is a lot harder to get their suicidal thoughts to improve. For example, in the best recent study on this (Gibbons RD, Brown CH et al: Arch Gen Psychiatry. 2012 Jun;69(6):580-7.Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine) there is about an 85% reduction in suicidal thinking in adults, whereas in young persons, there is only a 50-60% reduction. However there is no increase in the amount of suicidal thinking.
What to
do?
Be aware that a person with
depression can become more suicidal. Usually this happens within the first 30
days of starting an antidepressant.
Every person who is being
treated for depression should be asked about suicidal ideas on a regular basis,
whether they have starting antidepressants or not.
If a person is becoming more angry, more irritable, and bad tempered, call the
person who prescribed the medication or seek emergent care.
Remember that overall,
treatment of depression reduces suicidal thinking and attempts and suicide. Not
treating is much more dangerous.
The following drugs are in
this family:
SRIs for Depression
in adolescents and children
|
Drug |
Brand Name |
Usual Dosage |
Sizes |
comments |
|
Fluoxetine |
Prozac |
20-80 mg/d |
10, 20 |
Can be dissolved in water |
|
Citalopram |
Celexa |
40-60mg/d |
20,40 |
Cheapest drug available |
|
Sertraline |
Zoloft |
100-200mg/d |
25, 50, 100 |
Can be dissolved in water |
|
Escitalopram |
Cipralex |
20mg/d |
20 |
expensive |
Other medical treatments
Welbutrin (Buproprion)
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 USA for about 15 years. It is used primarily as an antidepressant.
However, it affects the same chemicals in the brain (dopamine and
norepinephrine) that other drugs for ADHD effect. As a result, it has been
tried in ADHD in children and adults. There are only a few studies of this drug
in children. However, all of them have found it to be effective. In the one
study which compared it to Ritalin, it was found to be almost, but not quite,
as effective as Ritalin for ADHD. (3) It comes in a slow release form which
means there is no need for a middle of the day dosage. The average dosage is
about 3mg/kg. However, sometime higher doses are used. The drug is available
only as a slow release preparation in Canada. It comes in 100mg 150 mg, and
300mg sizes. There is one good study which showed that it was better than
placebo for children with ADHD and depression.(39).
Side effects
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 Canada only causes seizures in
1 in 1000 people (9). This is about the same as most of the drugs used for
depression. Seizures have occurred in children, but usually at higher doses. It
is still unknown if the seizure rate in children is lower, higher, or the same
as in adults. There are no other long term side effects or risks. On the other
hand, it has not been around a long time. Over all, the early data suggests the
side effects are slightly less than stimulants, but not a lot less. (4)
Good points about Bupropion
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 USA for ADHD without any major problems.
If a child has failed to respond or tolerate the first line drugs and won't
have his blood drawn, it is a great choice. (5)
Bad points about Bupropion
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.
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.
SNRIs
(Serotonin Norepinephrine Reuptake Inhibitors)
This is a
class of medications that work in two ways in the brain on two different
neurotransmitter systems. One of those drugs, Venlafaxine, is very commonly
used in adults, but doesn’t seem to be helpful in adolescents, and in a recent
trial of treatment resistant depression, it caused more suicidal thinking and
attempts. The other drug, called Duloxetine, has only one study in the
literature to support its use. I have occasionally found it helpful when all
else fails.
Treatment
Resistant Depression in Adolescents
Sometimes the medicines don’t work, and we end up having to switch
medications, change the psychotherapy, and use multiple medications. The most
recent studies show that eventually about 2/3 of persons will get better
eventually. The main point is, the earlier they got treatment, the better they
did. (56)
Other drugs used in adults
–
The most
exciting studies in adolescent depression haven’t been published yet. There is
a whole class of drugs that are used for adults with treatment resistant
depression called second generation antipsychotics. One of them, Abilify, has a good side effect profile in young people,
but there are no data yet on whether it will work in major depressive disorder
in pediatrics.
Compliance
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.
Other treatments
Drug or alcohol
abuse treatment.
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.
Hospitalization
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 Southwestern Nova Scotia,
because there is no longer a child psychiatric unit. These children are placed
on the adult psychiatric ward with extra staff. Their hospital stay is usually
very brief.
Light
therapy
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.
Natural
Treatments
St. John's Wort
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 St.
John’s
Wort. This is probably because it is a fairly weak
substance and depression in children is harder, not easier to treat than in
adults.
Omega-3 Fatty Acids
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 Nova Scotia would call, “the floor of the fish plant”. As a
result, in my practice, only about ¼ of the children can tolerate it.
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)
Treating family members
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.
Depression in Mothers
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-
Examples
Mia and her mother Sally
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.
Tara and her mother Ann
Tara is 13.
She was brought to me because she confessed to her family doctor that she had
been cutting herself. She was, and it was quite serious. Tara had to be
hospitalized, and eventually ended up taking medications and counseling. With
all the excitement of suicide attempts, hospitalizations, and the like,
everyone forgot about asking Ann about her mood. Tara just did not get better.
Eventually the social worker helping the mother cope called to tell me about
mom’s depression. Too bad we hadn’t treated this before, as it might have
helped Tara get better faster.
This is why
the mother of everyone who comes to see me for depression gets to fill out a
screening test for depression.
How
long do you continue depression treatment?
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.
Prevention(14)
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?
Good
close friends and family
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.
Interested
and involved in school
If a child
is involved in school in every way they are more protected from depression.
Interested
and involved in outside school activities
The child
who is really "into" sports, clubs, church, arts, etc. is less likely
to get depressed.
Understand
what depression is
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
.
The four prong attack on depression
Identify!
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)
Treat!
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.
Prevent the
next episode!
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)
Prevent the
first episode!
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.
Putting
it all together-
Once
someone is diagnosed with depression, the next question is what to do?
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?
Examples
of treatment plans
Jeanette - mildly ill with
minimal co-morbidity
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.
What to do for Jeanette?
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
two months later.
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 - not too
ill, lots of comorbidity
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.
What to do for Rob?
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
2 months later.
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.
Rob
3 months later.
Rob has now had a 12 week
trial of Zoloft at 200 mg a day and he is no better. His Children's Depression
Rating Scale score is 43. We switch him over to Celexa
40mg a day.
Rob
4 months later.
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 - very ill
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.
What to do for Tanya?
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
in 2 months
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.
Rating
scales can really help determine if people are improved or not.
Stephanie - depressed now,
manic before
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.
What to do for Stephanie?
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.
In summary,
Depression is a relatively common psychiatric problem. It is frequently
found with other psychiatric problems. There are a number of different ways of
treating it, but none is without problems. It is up to the parents/caregivers,
child and the psychiatrist to figure out which treatment or treatments are best
for each situation. The most important thing is, do something!
In the short run, a depressed child may not seem like such a serious
thing. But in the long term the prospect of prolonged depression, harder to
treat depression, and suicide makes it very important to do what ever you can
to treat this horrible illness. Now.