Adolescent depression

Causes

Depression can be a response to many situations and stresses. In teenagers, depressed mood is common because of:

• The normal process of maturing and the stress that occurs with it
• The influence of sex hormones
• 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
• Failure at school

Teens who are most likely to become depressed when they experience stressful events:

• Have low self-esteem
• Are very critical of themselves
• Feel little control over negative events

Adolescent girls are twice as likely as boys to experience depression. A family history of depression also puts teenagers at greater risk.

The following events or situations can cause depression:

• Bullying or harassment at school or somewhere else
• Child abuse - both physical and sexual
• Lack of social skills
• Learning disabilities
• Long-term illness
• Poor parenting or caregiving
• Stressful life events, such as the loss of a parent to death or divorce

Many adolescents with depression may also have:

• Anxiety disorders
• Attention deficit hyperactivity disorder (ADHD)
• Bipolar disorder
• Eating disorders (bulimia and anorexia)

Symptoms

Depression can change the way teenagers see themselves, their lives, and the people around them. Teenagers who are depressed usually see everything more negatively. They can't imagine that any problem or situation can be solved in a positive way.

Some or all of these symptoms of depression may be present:

• Appetite changes (usually a loss of appetite but sometimes an increase)
• Difficulty concentrating
• Difficulty making decisions
• Episodes of memory loss
• Fatigue
• Feeling upset, restless, and irritable
• Feeling worthless, hopeless, sad, or self-hatred
• Loss of interest or pleasure in activities that were once fun
• Thinking or talking about suicide or death
• Trouble sleeping, too much sleeping, or daytime sleepiness

Sometimes a person's behavior may change, or there may be problems at home or school without any symptoms of depression:

• Acting-out behaviors (missing curfews, unusual defiance)
• Criminal behavior (such as shoplifting)
• Irresponsible behavior
• Poor school performance, grades dropping
• Pulling away from family and friends, spending more time alone
• Use of alcohol or other illegal substances

If these symptoms last for at least 2 weeks and affect your mood or ability to function, get treatment.

Suicide is a risk for all teenagers with depression. See: Suicide and suicidal behavior for more information on how to recognize and treat suicidal feelings.

Exams and Tests

True depression in teens is often difficult to diagnose, because normal teenagers have up and down moods. These moods may go back and forth over a period of hours or days.

Sometimes when children or adolescents are asked, they will say that they aren't happy or sad. Health care providers should always ask children or adolescents about symptoms of depression.

The health care provider will perform a physical examination and order blood tests to rule out medical causes for the symptoms. The doctor will also check for signs of substance abuse. The following can cause, or occur because of depression:

• Heavy drinking
• Regular marijuana (pot) smoking
• Other drug use

The health care provider will also check:

• The patient's history of sadness, irritability, and loss of interest and pleasure in normal activities
• Signs of other mental health problems, such as anxiety, mania, or schizophrenia
• Risks of suicide or homicide -- whether the teen is a danger to him or herself or others

Information from family members or teachers can often help identify depression in teenagers.

Treatment

Treatment options for adolescents with depression include:

• Supportive care from a medical provider
• Talk therapy
• Antidepressant medications (possibly)

Treatment should be tailored to the teenager, and the symptoms. Families often help in treating adolescent depression.

MEDICATION

The first medication tried is usually a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). Fluoxetine (Prozac) and escitalopram (Lexapro) are the only SSRIs approved for treating major depression in adolescents (ages 12 - 17). Fluoxetine is also approved for children age 8 and older.

NOTE: SSRIs and other antidepressants carry a warning that they may increase the risk of suicidal thoughts and actions in children and adolescents. Other evidence has not showed that these drugs increase suicide risk in children.

Doctors are still prescribing SSRIs and other antidepressant medications to adolescents with depression. Several important facts about taking any antidepressants include:

• Children and adolescents who take medications should be followed by a doctor for side effects. Parents or caregivers should watch for suicidal thoughts or behaviors, nervousness, irritability, moodiness, or sleeplessness that is getting worse. Get medical help for these symptoms right away.
• Do not stop taking medications without talking to your health care provider first.

Not all antidepressants are approved for use in children and teens. For example, tricyclic antidepressants are not approved for use in teens.

TALK THERAPY

Almost all adolescents with depression benefit from some type of talk therapy. Talk therapy is a good place to talk about their feelings and concerns, and to learn ways to deal with them.

Types of talk therapy include:

• Cognitive-behavioral therapy teaches depressed people ways of fighting negative thoughts. It makes people more aware of their symptoms, helps them learn what makes their depression worse, and teaches them problem-solving skills.
• Family therapy may be helpful if family conflict is contributing to the depression. Support from family or teachers may help with school problems.
• Talk therapy (psychotherapy) can help adolescents understand issues that may be causing their behavior, thoughts, or feelings.
• Joining a support group of people who are experiencing problems like yours can also help. Ask your therapist or doctor for recommendations.

Sometimes people with severe depression, or those who are suicide risks may need to stay in the hospital for treatment.

Adolescents with depression should learn to:

• Take medications correctly and manage their side effects
• Watch for early signs that depression is getting worse, and react when it happens
• Exercise more and seek out other activities that they enjoy
• Avoid alcohol and drugs (whether or not they have been prescribed). These substances affect the brain and make the depression worse over time. They may also affect judgment about suicide.
• When you are struggling, talk to someone you trust about how you are feeling. Try to be around people who are caring and positive.

Outlook (Prognosis)

Depression usually responds to treatment. Getting the right treatment as early as possible may prevent further episodes. However, about half of very depressed teens will keep having problems with depression as adults.

Possible Complications

• Drug, alcohol, and tobacco abuse
• Effects on school performance and relationships
• Other mental health problems, such as anxiety disorders
• Teenage suicide
• Violence and reckless behavior

Adolescents with other mental health problems usually need longer and more intensive treatment.

When to Contact a Medical Professional

There are numbers you can call from anywhere in the United States, 24 hours a day, 7 days a week: 1-800-SUICIDE or 1-800-999-9999.

Call your health care provider right away if you notice one or more of these suicide warning signs:

• Giving possessions to others
• Personality change
• Risk taking behavior
• Threat of suicide or plans to hurt yourself
• Withdrawal, urge to be alone, isolation

See: Suicide and suicidal behavior for more information

Call your health care provider if you notice:

• Depression that is not improving or is getting worse
• Nervousness, irritability, moodiness, or sleeplessness that is new or getting worse
• Side effects of medications

NEVER IGNORE A SUICIDE THREAT OR ATTEMPT!

Prevention

Most teenagers feel down sometimes. Having support and good coping skills can help prevent these periods of sadness from leading to more severe depression. Talking openly with your teen can help identify depression early.

Make sure your teen gets professional help to deal with periods of low mood. Identifying and treating depression early may prevent or delay episodes.

In homes with adolescents:

• Do not keep alcohol in the home or keep it securely locked
• Lock all guns and keep ammunition separate
• Lock up all prescription medications

Alternative Names

Depression - adolescents; Teenage depression

References

US Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics. 2009;123:1223-1228.

Zuckerbrot RA, Cheung AH, Jenson PS, Stein REK. Identification, assessment, and initial management guidelines for adolescent depression in primary care. Pediatrics. 2007;120:e1299-e1312.

Cheung AH, Zuckerbrot RA, Jenson PS, Ghalib K. Treatment and ongoing management guidelines for adolescent depression in primary care. Pediatrics. 2007;120:e1313-e1326.

Bostic JQ, Prince JB. Child and adolescent psychiatric disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 69.

Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. National Institute of Mental Health (NIMH). January 13, 2010. Accessed March 25, 2012.

Update Date: 3/25/2012

Updated by: Timothy Rogge, MD, Medical Director, Family Medical Psychiatry Center, Kirkland, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.