Depression - adolescents; Teenage depression
A disorder occurring during the teenage years marked by persistent sadness, discouragement, loss of self-worth, and loss of interest in usual activities.
Causes, incidence, and risk factors
Depression can be a transient response to many situations and stresses. In adolescents, depressed mood is common because of the normal maturation process, the stress associated with it, the influence of sex hormones, and independence conflicts with parents.
It may also be a reaction to a disturbing event, such as the death of a friend or relative, a breakup with a boyfriend or girlfriend, or failure at school. Adolescents who have low self-esteem, are highly self-critical, and who feel little sense of control over negative events are particularly at risk to become depressed when they experience stressful events.
True depression in teens is often difficult to diagnose because normal adolescent behavior is marked by both up and down moods, with alternating periods of feeling ‘the world is a great place’ and ‘life sucks’. These moods may alternate over a period of hours or days.
Persistent depressed mood, faltering school performance, failing relations with family and friends, substance abuse, and other negative behaviors may indicate a serious depressive episode. These symptoms may be easy to recognize, but depression in adolescents often manifests very differently than these classic symptoms.
Excessive sleeping, change in eating habits, even criminal behavior (like shoplifting) may be signs of depression. Another common symptom of adolescent depression is an obsession with death, which may take the form either of suicidal thoughts or of fears about death and dying.
Long-term depressive illness usually has its onset in the teen or young adult years - about 15% to 20% of American teens have experienced a serious episode of depression, which is similar to the proportion of adults suffering from depression.
Adolescent girls are twice as likely as boys to experience depression. Risk factors include stressful life events, particularly loss of a parent to death or divorce; child abuse; unstable caregiving, poor social skills; chronic illness; and family history of depression.
- depressed or irritable mood
- temper, agitation
- loss of interest in activities, apathy
- reduced pleasure in daily activities
- inability to enjoy activities which used to be sources of pleasure
- change in appetite, usually a loss of appetite but sometimes an increase
- change in weight (unintentional weight loss or unintentional weight gain)
- persistent difficulty falling asleep or staying asleep (insomnia)
- excessive daytime sleepiness
- difficulty concentrating
- difficulty making decisions
- memory loss (amnesia) episodes
- preoccupation with self
- feelings of worthlessness, sadness, or self-hatred
- excessive or inappropriate feelings of guilt
- acting-out behavior (missing curfews, unusual defiance)
- thoughts about suicide or obssessive fears or worries about death
- plans to commit suicide or actual suicide attempt
- excessively irresponsible behavior pattern
If these symptoms persist for at least two weeks and cause significant distress or difficulty functioning, treatment should be sought.
Signs and tests
- physical examination and blood tests to rule out medical causes for the symptoms (for example: hypothyroidism, pregnancy, kidney disease).
- evaluation for substance abuse - heavy drinking, frequent marijuana smoking, and other drug use can be both causes and consequences of depression. Past practice in addiction treatment was to assume depression was only a symptom of use, not a potential cause, and it was left untreated. Research now shows that this leads to increased risk of relapse. If a substance abuse problem is found, be sure that psychiatric evaluation doesn’t stop at diagnosing this, but continues to assess depression and other potential psychiatric problems.
- psychiatric evaluation to assess a history of persistent sad, empty, or irritable mood and loss of interest or pleasure in normal activities. Evaluation for other potentially co-existing psychiatric disorders (such as anxiety, mania, or schizophrenia).
- assessment of suicidal/homicidal risks.
- information from family members or school personnel is often helpful in identifying depression in teens.
Treatment options for adolescents with depression are similar to those for depressed adults, and include psychotherapy and antidepressant medications (see major depression for a review of treatments and self-care). However, one major antidepressant, Paxil, now has a warning NOT to be given to children under 18.
Family therapy may be helpful if family conflict is contributing to the depression. Support from family or teachers to help with school problems may also be needed. Occasionally, hospitalization in a psychiatric unit may be required for individuals with severe depression, or if they are at risk of suicide.
Because of the behavior problems that often co-exist with adolescent depression, many parents are tempted to utilize punitive solutions like “boot camps”, “wilderness programs”, or “emotional growth schools.”
These programs frequently utilize non-professional staff and use confrontational therapies and harsh punishments. There is no scientific evidence which supports use of these programs. In fact, there is a growing body of research which suggests that they can actually harm teens, particularly sensitive teens with depression.
Depressed teens who act out may also become involved with the criminal justice system. Parents are often advised not to intervene, but to “let them experience consequences.”
Unfortunately, this can also harm teens through exposure to more deviant peers and reduction in educational opportunities. A better solution is to get the best possible legal advice and search for treatment on your own, which gives parents more control over techniques used and options.
Though a large percentage of teens in the criminal justice system have mental disorders like depression, few juvenile prisons, “boot camps” or other “alternative to prison” programs provide adequate treatment.
Depressive episodes usually respond to treatment, and early and comprehensive treatment of depression in adolescence may prevent further episodes. However, about half of seriously depressed teens are likely to have continued problems with depression as adults.
Teenage suicide is associated with depression as well as many other factors. Depression frequently interferes with school performance and interpersonal relationships. Teens with depression often have other psychiatric problems, such as anxiety disorders.
Depression is also commonly associated with violence and reckless behavior. Drug, alcohol, and tobacco abuse frequently coexist with depression. Adolescents with additional psychiatric problems usually require longer and more intensive treatment.
Calling your health care provider
Call your health care provider if one or more warning signs of potential suicide are present.
Although there is no one type of suicidal person, be alert to the following signs:
- withdrawal, with urge to be alone, isolation
- personality change
- threat of suicide
- giving most cherished possessions to others
NEVER IGNORE A SUICIDE THREAT OR ATTEMPT!
Periods of depressed mood are common in most adolescents. However, supportive interpersonal relationships and healthy coping skills can help prevent such periods from leading to more severe depressive symptoms. Open communication with your teen can help identify depression earlier.
Counseling may help teens deal with periods of low mood. Cognitive behavioral therapy, which teaches depressed people ways of fighting negative thoughts and recognizing them as symptoms, not the truth about their world, is the most effective non-medication treatment for depression. Ensure that counsellors or psychologists sought are trained in this method.
For adolescents with a strong family history of depression, or with multiple risk factors, episodes of depression may not be preventable. For these teens, early identification and prompt and comprehensive treatment of depression may prevent or postpone further episodes.
Revision date: June 21, 2011
Last revised: by Jorge P. Ribeiro, MD