Depression in young people
Symptoms of depression in young people
There are many similarities between depression in children and depression in adults but there are also important differences.
Many of the symptoms of depression are the same in young people as they are in adults. As with adults, there is a change in mood that persists over time. There are physical symptoms such as poor sleep or too much sleep and low energy levels, and there are psychological symptoms such as poor concentration, and a negative view of the world and their place in it.
However, many young people will deny feeling sad even though their behaviour has changed, and they will be more grumpy or irritable. There is no consistent way in which depression in children shows itself. Some come to the attention of GPs because they complain of headaches, stomach pains or bone pain but no cause can be found. Others present for the first time with self-harm, disinterest in general appearance, withdrawal and loss of interest, but in others a change in behaviour such as a decline in schoolwork or increased argumentativeness is the first sign.
Symptoms of depression vary according to age. Children are more likely to complain of physical problems such as headaches and abdominal pains and tend not to look depressed. Adolescents are more likely to complain of low mood and to have a higher rate of suicidal thoughts.
Moody or depressed?
National surveys have shown that many young people have some depressive symptoms but they are not serious enough to be considered an illness or need treatment.
Trying to disentangle depression from normal mood problems in teenagers can be difficult. One indication is that depressed teenagers often no longer derive pleasure from life and have poor self-esteem. They may have little to say when asked about their good points, they think that they are no good and that the situation in which they find themselves is their fault, but they do not have the ability to change things. When this is coupled with the adult symptoms of depression, such as poor concentration, loss of confidence and in severe cases delusions and suicidal thoughts, the diagnosis is not too difficult.
Depressive illness is diagnosed when the symptoms lead to significant personal suffering and social impairment.
It often takes time to make the diagnosis. As with adults, many young people are not forthcoming when seeing a doctor or therapist. As with adults depression can also be considered as mild, moderate or severe, depending on the number and intensity of symptoms that are present.
One rule of thumb is that depression needs treating only if it stops someone from doing things that they want to or changes their ability to do things, for instance interferes with their schoolwork. Otherwise minor symptoms can just be monitored.
Risk factors and figures
Depression is less common in young people than it is in adults. Each year one per cent of pre-pubertal children and three per cent of post-pubertal adolescents suffer from depression.
Some of the underlying causes of depression in children are similar to the causes for depression in adult life, for instance genes, personality or family environment. Others, such as bullying, being put into care, personality and social development in adolescence and changes in hormones and brain development, are specific to young people.
More than 95 per cent of major depressive episodes in young people arise in children and young people with long-standing difficulties, such as family or marital disharmony, divorce and separation, domestic violence, physical and sexual abuse, school difficulties and exam failure.
A very small number of depressive episodes in children and young people will arise in the absence of prior difficulties, and result from an acute life event such as a mugging.
Depression is triggered by an event that has a high negative impact, for instance parental separation or getting into relationship difficulties with a close friend.
Social stress seems to be an important underlying factor because the rates of depression are higher in poorer households, households with single parents, in families where parents did less well at school and in children who are in local authority care or young offender institutions.
Depression in children and young people tends to occur in conjunction with other mental health problems such as abuse of drugs or alcohol or hyperactivity.
Treatment of depression in childhood
Most young people who are depressed do not get treatment. This is because they are reluctant to seek help as a result of the stigma of mental health problems, but they also do not get help because depression is missed by parents, health professionals and teachers. Depression is missed in three-quarters of young people who suffer from it.
Treatment strategies should be aimed at the whole child. Many young people with depression suffer from other mental health problems and there are often social and family issues, so everything has to be dealt with. Attention should be paid to the possible need for treatment of the parents’ own psychiatric problems, for instance depression.
A treatment programme should aim to:
• cure the depression
• improve other mental health problems
• improve social and emotional development and school performance
• decrease family distress
• reduce the risk of relapse.
Treatment for depression in young people can occur at one of three levels.
Level 1
Services include GPs, paediatricians, health visitors, school nurses and social workers
Level 2
Services include child and adolescent mental health services such as clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors and family therapists.
Level 3
Services include child and adolescent psychiatry day units, highly specialised outpatient teams and inpatient units (inpatients are hospitalised, outpatients receive treatment at a hospital but then return home).
Most young people with depression are treated in level 1 and 2 services. Very few are ever admitted to a specialist inpatient unit.
Mild depression
Mild depression in young people is usually treated by a family doctor and other level 1 services. Most GPs will assess the young person and the family. A good GP will give the patient the opportunity to be seen alone as well as with a parent.
If after assessment there are considered to be complicating factors, for example other significant risk factors such as suicidal thoughts, mental health problems such as substance misuse or mental health problems in other family members, the GP may decide to refer direct to level 2 services.
In cases where there is no indication of suicidal thoughts or any other significant problem GPs usually start with watchful waiting – seeing the person again in two weeks and then after another two weeks to see whether the depression rights itself.
If after a month of watchful waiting, things have not improved then one of three interventions will usually be offered for up to three months:
1 individual supportive psychotherapy
2 group cognitive–behavioural therapy
3 guided self-help.
Antidepressant medication should not be used for the initial treatment of children and young people with mild depression.
If after three months of treatment the depression has not responded a specialist opinion is needed.
Moderate-to-severe depression
Most GPs refer young people with depression to a child and adolescent psychiatric service only if they have complex problems, if they have not responded to three months of treatment or if from the outset they have moderate-to-severe depression, recurrence of depression, suicidal ideas or plans or unexplained self-neglect of at least one month’s duration. However, if you ask for a referral most GPs will oblige.
Children and young people with moderate-to-severe depression should be offered, as a first-line treatment, a specific psychological therapy such as individual cognitive–behavioural therapy, interpersonal therapy or family therapy for at least three months. If this does not work additional therapy on a one-to-one basis for the young person or parents may be considered.
Given the complex and serious nature of depression, a number of professionals may be involved, each trying to improve a specific aspect of the problem. For instance, in addition to a psychiatrist, educational psychologists may be helping with school, family therapists with family difficulties, and social workers with financial, housing or legal problems.
Medication
If psychological therapies are not effective, doctors may consider adding medication to the treatment. Antidepressant medication should be offered only in combination with psychological therapies. If psychological therapies are refused antidepressants can be prescribed alone but there needs to be close monitoring – preferably weekly for at least the first four weeks. This is because side effects need to be assessed and because in some young people antidepressants make them feel more suicidal.
In those aged over 12 there is some evidence that one drug – fluoxetine, an SSRI (selective serotonin release inhibitor) – is effective. In the 5-to 11-year-old group the evidence that any drug is effective is sparse. If fluoxetine is not effective another antidepressant may be tried.
Admission to a hospital
Admission to a hospital unit for level 3 services may be considered if the child/young person is at high risk of suicide, serious self-harm and self-neglect, the required intensity of treatment (or supervision) is not available in the community or intensive assessment is needed.
Once depression has resolved
A young person who has suffered from depression is at increased risk of another bout. As a result of this services will usually keep an eye on the person for at least a year after the depression has resolved. In addition, they will fast-track them if symptoms return.
What is the outlook?
Depression in children is a serious illness. With no treatment only ten per cent will recover within three months. Leave it for a year and half will have recovered. Treatment decreases the duration of the illness.
The most serious complication of depression is suicide with three per cent of depressed children killing themselves within the next ten years; other problems are poor school performance and difficulties in personality development. One in three young people with depression has a recurrence within five years and many develop episodes into adult life.
