by Richa Bhatia, MD, FAPA

Rates of childhood depression have been rising in the last several years. Yet, information and awareness about childhood depression has not caught on at the same rate. Millions of people across the world wonder and doubt if children can get depressed. Many well-intentioned adults still believe that children ‘can’t get depressed. They are so young- what do they have to be depressed about? When we were that age, we were just happy’. Alongside misunderstanding is stigma and the idea that mental illness is a taboo subject. 

What we now know: 

  • Childhood depression is a real, distinct clinical entity. 
  • It is a serious health condition, which if left untreated, increases risk of future, prolonged and more severe depressive episodes. Untreated depression in childhood and adolescence can pose risk of suicide.
  • Depression often has biological, psychological and social underpinnings. An individualized treatment plan that explores and addresses each of these aspects, works best. 
  • Effective treatment options for childhood and teen depression have been widely tested, proven and established, through several scientific studies over the years.
  • Childhood depression can be hidden and therefore, easily missed. Timely recognition and treatment can be life-changing and life-saving.
  • The barriers surrounding mental health stigma are beginning to give way due to powerful social movements and discussions that address realities of mental health.

Who is Affected by Depression in Childhood or Teenage?

Depression can affect anyone. However, children or teens who have immediate family members with a history of depression or other mood disorders (such as bipolar disorder) are more likely to suffer from depression, often due to a genetic predisposition. Predisposition implies greater likelihood; it does not mean that the child or teen will necessarily experience depression.

Children with chronic or severe medical conditions are at a greater risk of suffering from depression.

Common Signs of Depression in Childhood or Adolescence

Depression in childhood/adolescence can manifest somewhat differently than it does in adults. Irritability and/or anger are more common signs of depression in children and teens. 

When depressed, younger children are more likely to have physical or bodily symptoms, such as aches or pains, restlessness, distress during separation from parents, as they may not have the emotional attunement and/or expressive abilities to talk about their emotions.

Other signs of depression in children and teens, can be:

  • Loss of interest in usual fun activities
  • Withdrawal from social or usual pleasurable activities
  • Difficulties with concentration
  • Running away from home or talking about running away from home
  • Talking about death or dying, giving away (or talking about giving away) favorite possessions, writing goodbye letters
  • Sleep increase (or decrease)
  • Appetite/weight changes (more likely an increase, in depressed teens)
  • Occasionally, new or recent onset agitation or aggression
  • Comments indicating hopelessness or low self-worth

Not all of the above-mentioned symptoms have to be present for a diagnosis of depression. Symptoms usually occur on most days, for at least 2 weeks, in order to meet criteria for depression. When seeing a professional to explore a diagnosis, you can utilize online health resources to prepare meaningful questions to ask a doctor in order to facilitate productive conversation for treatment.

Ruling Out Medical Conditions First

Psychiatric disorders are diagnosis of exclusion, which means that only if the symptoms are unexplained by medical conditions, or effect of substances or other non-psychiatric causes, would the cause of symptoms be deemed to be due to a primary psychiatric disorder.

Before arriving to the diagnosis of depression, a child or teen who is suspected to be depressed, must undergo a comprehensive medical evaluation to rule out any underlying medical condition which could be manifesting as or resulting in depression. For example, hypothyroidism (depressive symptoms, weight gain, low energy, cognitive difficulties, constipation). Even conditions such as undiagnosed anemia can mimic depression, due to accompanying fatigue/low energy. Vitamin D deficiency, common in cold climates, increases risk of depressive symptoms and fatigue. The good news is that these conditions have effective treatments, and treatment of the underlying medical condition in a timely manner should resolve depressive symptoms.

Ruling Out Other Psychiatric Conditions

Rule out undiagnosed/untreated ADHD (attention Deficit Hyperactivity Disorder), anxiety disorders or other psychiatric conditions, which when left untreated, can result in depressive symptoms due to the impairment in functioning from ADHD or anxiety disorder itself. 

Treatment

Why Treat?

Depression is associated with visible brain changes seen on functional brain MRI studies of depressed individuals. Treatment, for example, psychotherapy has been shown to confer long term benefit and neural changes in the brain. 

How Do I know My Child Needs Treatment?

In addition to an overall assessment, your child’s pediatrician may administer rating scales and other forms of assessment to determine the degree of depression and may refer you to a psychiatrist or a psychotherapist.

We know a child/teen needs treatment for depression when their school, social, and/or home functioning is significantly affected by depressive symptoms, on a frequent basis. 

If your child/teen is feeling suicidal and/or having thoughts/urges to hurt themselves, call 911 or take your child/teen to the nearest ER. 

What Kind of Treatment?

For mild to moderate depression, CBT (Cognitive Behavioral Therapy) is the typical first-line treatment of choice for children and teens. There can be exceptions to this, depending on the specific clinical condition, age and circumstance of the child. For children younger than 10, other modalities of psychotherapy such as play therapy, psychodynamic psychotherapy, and behavior therapy may be utilized. 

For moderate to severe depression, evidence-based guidelines recommend a combination of CBT and antidepressant medications (typically SSRI medications, also known as Selective Serotonin Re-Uptake Inhibitors).

SSRI Use for Depression in Children

  • SSRIs and other antidepressants have a black box warning from FDA about risk of increase in suicidal thoughts and behavior with use, particularly in the early phase of treatment. Studies did not show completed suicides.
  • After this warning came out in 2004, antidepressant prescription rates dropped, and suicide rates climbed up. 
  • Close monitoring during dose initiation, titration and dose changes helps to reduce this risk 
  • Antidepressant medication use in children and adolescents is preceded by a weighing of benefits and risks of use versus risks of untreated depression.
  • Fluoxetine and Escitalopram are FDA approved for treatment of depression in children and teens. 
  • Studies involving paroxetine (another SSRI) have shown a higher profile of side effects with its use in children, and therefore, may not be recommended for children and teens.
  • Studies show a higher likelihood of an individual responding to an SSRI that an immediate family member benefitted from (however, this is a likelihood, not necessary that it will happen in each situation)

If depressive symptoms are secondary to other conditions, such as untreated ADHD or anxiety disorders, adequate treatment of those disorders is essential and will usually resolve the depressive symptoms. However, in certain situations, specific antidepressant medications and/or psychotherapy targeted towards depression may be needed in addition. One might note that if trials of two or more antidepressants are not effective, or if a child/teen is sensitive to medications in general, there are additional avenues that can be explored. One plausible route for consideration is genetic testing that combines personal genetic data with medication information to achieve the desired remedy.

Your child’s pediatrician/psychiatrist, therapist, together with you, may also explore for any bullying, trauma, and will try to understand your child/teen’s inner life and look further for any school, social, family or other stressors that may be contributing to, or exacerbating/perpetuating the depressive condition. If family stressors are significantly contributing to your child’s depression, your doctor may recommend family therapy in addition. With your permission, the doctor/therapist may coordinate with your child’s school to share recommendations to optimize your child’s school functioning and emotional well-being at school. 

Overcoming Mental Health Stigma

In 1999 the United States Surgeon General labeled stigma as quite possibly the biggest barrier to mental health care. Stigma manifests as misguided stereotypes and negative attitudes or beliefs towards those with mental illness. Research shows that stigma and embarrassment were the top reasons why people with mental illness did not engage in medication adherence, such as self-care, therapy and medication compliance. As of late, there has been an increase in available resources and tools to overcome stigma for children and teens, as well as their caregivers. Allies such as Bring Change to Mind, an organization focused on encouraging dialogue about mental health, as well as raising awareness through education, offers high-school and college programs that foster a culture of peer support within schools.

A Word About Substance Use and Depression

Sadly, substance use among teens is becoming rampant across the country, even in reputed school districts, and thus, needs to be addressed when exploring and treating depression.

Marijuana use is particularly common among teens. Marijuana is considered to be a ‘gateway drug’ and can lead to ‘amotivational syndrome’. This syndrome manifests as low motivation to do things, and in conjunction with marijuana related ‘munchies’ can mimic a primary depressive disorder. In many cases, a teen may be ‘self-medicating’ for untreated or undiagnosed depressive or anxiety symptoms through substance use. Use or withdrawal from other substances can cause depressive, mood symptoms as well. 

Proper and timely treatment can be very effective in resolving depressive symptoms and in reducing risk of relapse. Please consult your child’s pediatrician or health care provider if you suspect your child/teen may be suffering from a medical or a psychiatric condition. 

Note: This article is for informational purposes only and is not intended to provide medical or psychiatric advice or recommendations, or diagnostic or treatment opinion. This is not a complete review or description of this subject. If you suspect a medical or psychiatric condition, please consult a health care provider. All decisions regarding an individual’s care must be made in consultation with your healthcare provider, considering the individuals’ unique condition. If you or someone you know is struggling, please contact the 24x7, confidential National Hotline at 1-800-273-8255 or use the crisis text line by texting HOME to 741741 in the US, or go to http://www.suicide.org/international-suicide-hotlines.html for the suicide hotline number for your country.


About the author: 

Richa Bhatia, MD, FAPA is a Child, Adolescent and Adult psychiatrist, dual Board certified in Child, Adolescent and General Psychiatry. She is the author of 2 books: ‘Demystifying Psychiatric Conditions and Treatments’ and ‘65 Answers about Psychiatric Conditions’. Previously, she served as a faculty member in the departments of psychiatry at Harvard Medical School and Geisel School of Medicine at Dartmouth. She serves as an Associate Editor for Current Psychiatry, Section Editor for Current Opinion in Psychiatry and is on the editorial board of several other psychiatry journals. She is an expert contributor for Psychology Today and Thrive Global. Some of her interests are childhood depressive and anxiety disorders, the interface between medical and psychiatric conditions, differential diagnosis, compassion and bullying prevention. She is an active member of the Child and Adolescent Psychiatry Section of the World Psychiatric Association (WPA), the American Psychiatric Association and the Anxiety and Depression Association of America.