After completing this article, readers should be able to:
Discuss the prevalence of depressive disorders.
Recognize the comorbidities of early-onset depressive disorders.
Explain how pediatricians and other caregivers can help youth who may be depressed.
Describe the first line of treatment for youth who have depressive disorders.
Discuss the incidence of suicidal ideation, attempted suicide, and suicide in adolescence.
List the risk factors for suicide by youth.
Most youth occasionally experience the blues, feel sad, or become irritable. Nevertheless, it is important to consider the possibility of a depressive disorder when a depressed or irritable mood is more than temporary, occurs in conjunction with other symptoms, or interferes with daily functioning. Major depressive disorder (MDD) is manifested by a depressed or irritable mood or diminished interest or pleasure that lasts for at least 2 weeks. This is accompanied by changes in cognitive and physical functioning. Dysthymic disorder (DD) is a less severe type of depression that involves chronic symptoms and lasts for at least 1 year. These specific types of depressive disorders are the focus of this article.
Depressive disorders can be identified in children of all ages, but they become increasingly prevalent during adolescence. In fact, the peak ages of depressive symptom onset in lifespan studies are 15 to 19 years and 25 to 29 years. The sharpest rise in prevalence occurs among girls during adolescence and early adulthood. Approximately 2% of school-age children and 4% to 6% of adolescents struggle with MDD at any one point in time. Lifetime prevalence rates by late adolescence range between 20% and 25%.
Prior to puberty, there is about a 1:1 gender ratio for depressive disorders. After puberty, this shifts to a 2:1 ratio of females to males, which continues throughout adulthood. A combination of hormonal and social changes during puberty may explain the differing rates of depression among males and females.
Depression has a complex genetic and environmental basis. Adoption, twin, and family studies all point to the impact of genetic factors, which seem to establish a young person’s biologic vulnerability for depression. The onset of a depressive episode, however, often is precipitated by difficult life events or stressful experiences such as a parental divorce, school change, or relationship breakup. Other environmental risk factors include maltreatment (sexual abuse, physical abuse, or neglect). The pathways to depression are complex and variable. Some depressive disorders are more biologic; others are more situational.
The symptoms of MDD and DD, as outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994), include changes in physical, cognitive, and emotional domains (Tables 1 and 2).
In 1996, the World Health Organization ranked depression among the most disabling of all diseases in the world, leading all other disorders in “years lived with disabilities.” The reasons for this are apparent when one considers the course of depressive illness. Approximately 70% of youth who have MDD experience another depressive episode within 5 years, and youth who have depressive disorders have a fourfold risk of an adult depressive disorder. Approximately 50% of children and adolescents who have MDD can be expected to have adult recurrences. Early onset and recurrences also have been described as a cause of treatment-resistant depression in later life, leading to multiple episodes that last longer, become more severe, and become more difficult to treat. These tend to be associated with more hospitalizations, job absenteeism, and impaired work performance.
Depressive disorders in youth are associated with impaired functioning in several areas of daily living. These include strained family and peer relationships, school attendance difficulties, and academic performance problems. Affected youth often experience suicidal thoughts and are at increased risk for attempted and completed suicide.
Differential Diagnosis and Comorbid Conditions
Early-onset bipolar disorder (BD) often presents as depressive symptoms, which can make it difficult to distinguish between bipolar and unipolar depression. BD is characterized by alternating periods of mania and depression. The inflated self-esteem, excess energy, and poor judgment that characterize a manic phase often result in dangerous activity and substantial social problems. Rapid cycling and mixed symptom states occur in subtypes of BD. Approximately 20% to 40% of children who have MDD eventually develop BD. Some clues to the risk for developing a manic or hypomanic episode include psychosis, psychomotor retardation, or a family history of BD.
Another potential diagnostic dilemma occurs when a child or adolescent is abusing alcohol or drugs. Youth are not always forthcoming about such abuse, which may be associated with declining school performance, withdrawal from usual social activities, sleep disturbance, and negative moods. Careful questioning of the youth and parent/guardian is necessary to identify a substance use disorder in youth presenting with depressive symptoms. It can be equally challenging to identify a depressive disorder in youth initially identified for services because of problems related to alcohol or substance abuse.
Most children and adolescents who are depressed also have a history of some other psychiatric or alcohol/drug use disorder. For example, 25% to 75% of depressed youth have one or more anxiety disorders, such as separation anxiety disorder or social phobia. Disruptive behavior disorders, such as attention-deficit disorder or oppositional defiant disorder, are also common, and substance abuse or dependence characterizes a significant minority of youth who are depressed. A gender difference exists in patterns of comorbidity. Girls more commonly have comorbid anxiety conditions; boys are more likely to have comorbid conduct disorders or substance use disorders.
Children and adolescents rarely seek professional treatment. Thus, parents, teachers, pediatricians, and others who have regular contact with youth play critical roles in recognizing youth who are depressed. Few youth use the word “depressed”; even fewer report to someone that they may be experiencing a clinical depression. Therefore, it is helpful to ask youth about experiences of feeling down, “bad,” miserable, bored, or irritated. Signs of clinical depression that often initially are visible to others include withdrawal from activities, decline in school performance, change in sleep patterns, and sadness or irritability.
The United States Preventive Services Task Force recently recommended the use of two questions in screening for depression among adults: “Over the past 2 weeks, have you ever felt down, depressed, or hopeless?” and “Have you felt little interest or pleasure in doing things?” The Task Force concluded that evidence is inconclusive regarding the effectiveness of routine screening of children and adolescents, but these two questions may help clinicians detect primary symptoms of depression. More comprehensive screening instruments and diagnostic tools or a referral to a mental health professional should be considered if indicated. The Reynolds Adolescent Depression Inventory (RADS) and the Children’s Depression Inventory (CDI) are screening tools used in some school and mental health clinics.
Clinical interviews are the cornerstone of a comprehensive assessment and should include, at a minimum, interviews with the youth as well as the parent or guardian. In addition to gathering a complete history of presenting problems (onset, chronicity, severity, prior history of symptoms, and treatment), a full psychiatric interview is conducted to obtain information about possible comorbid conditions. For example, it is critical to ascertain whether psychotic features, disruptive behavior disorders, anxiety disorders, or substance abuse problems are present. Information also is gathered about the youth’s medical, developmental, social, and educational histories as well as the family psychiatric history.
Important sources of information may include school academic and attendance records; teacher reports; and appropriate biomedical, psychological, or other test findings. Standardized self-report questionnaires may permit youths to answer questions about current symptoms without directly verbalizing the extent of their emotional distress to an adult. This approach sometimes can facilitate honest reporting of the number and severity of depressive symptoms. If noted in a self-report questionnaire, critical items always should be followed up with direct inquiry by the clinician (eg, if a youth reports suicidal ideation).
The initial goals of treatment are to ensure the youth’s safety and develop an effective therapeutic alliance with the youth and parents. This alliance will facilitate ongoing communication and continuation of care. Consultation with teachers and other caregivers also is important. A focus on patient and family education and a collaborative approach to treatment planning can enhance the youth’s adherence to treatment recommendations.
Psychoeducation is a key component of the treatment. Beyond this, perspectives on the first line of treatment vary. The choice of whether to begin with psychotherapeutic or psychopharmacologic interventions or a combination depends on depression severity and chronicity, prior history of depressive episodes, likelihood of adherence, previous response to treatment, patient and family motivation for treatment, and availability of resources. Because of the psychological, environmental, and social problems associated with depression and its treatment, pharmacotherapy usually is not sufficient as the sole treatment. Attention to parental mental health and family stress as well as to strategies for helping parents manage the youth’s irritability, isolation, or other problems should be included in psychotherapeutic interventions. These systemic concerns affect treatment adherence and ultimate outcomes.
Psychoeducation addresses the signs and symptoms of depression; the importance of psychotherapy and psychiatric medication; and common misconceptions about the illness, therapy, or medications. It also is helpful to address the impact that depression has on school, social, and family functioning and the ways in which parents and teachers may aid in recovery. Parent and family education may increase adherence and reduce self-blame. Education of parents can help them identify their own mood disorders and potential treatment needs as well. Education also can reduce blame for symptoms such as irritability and anhedonia that may affect others.
Controlled studies have documented the short-term effectiveness of cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) for depressed youth. Both generally are time-limited therapies that involve collaboration or guided discovery between the therapist and adolescent. CBT focuses on self-understanding of negative mood states and on the identification and modification of negative, distorted thought patterns. It also emphasizes problem-solving skills, communication skills, and the development of more adaptive behavior patterns. IPT strives to improve the youth’s interpersonal functioning by improving self-understanding, problem-solving, communication, and coping in the realm of relationships. It focuses on a chosen interpersonal problem such as grief, a difficult role transition, an interpersonal conflict or role dispute, social skill deficits, or issues in step-parent families. Although randomized, controlled clinical trials have not been conducted for psychodynamic therapy with depressed youth, this approach may be useful. Family therapy is an important supplement to any of these approaches if difficulties in family communication and support are identified. Goals of family therapy may include improving family affective communication, increasing adaptive behaviors, and changing both interpersonal and family functioning.
Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice for youth who require pharmacotherapy (American Academy of Child and Adolescent Psychiatry, 1998). The efficacy of the SSRI fluoxetine in reducing depressive symptom severity in children and adolescents has been demonstrated in two double-blind, randomized, placebo-controlled trials. Paroxetine also has demonstrated efficacy compared with imipramine and placebo in a double-blind, placebo-controlled comparison. Other antidepressant medications are not well studied. Dosing guidelines recommend starting with 10 mg fluoxetine and increasing to 20 mg. The maximum dose is 40 mg to 80 mg. When treating a child younger than 8 years of age, clinicians may want to start with 4 to 8 mg elixir of fluoxetine. However, the efficacy and safety data have been demonstrated only down to age 8 years. If there are problems with insomnia, appetite loss, or restlessness, paroxetine is a more sedating SSRI, and dosing guidelines are identical to those for fluoxetine. SSRIs should be discontinued if symptoms of mania appear. However, youth may benefit from treatment with an SSRI for an extended period before BD develops.
An adequate trial of SSRIs is at least 4 to 6 weeks. If no or only minimal improvement is observed, a dose increase should be considered and medication continued for at least 4 to 6 additional weeks. If no improvement has been observed, alternative strategies should be considered, including a referral to a psychiatrist in cases of treatment-resistant depression. Additionally, if the pediatrician is not comfortable in the prescriber role, a psychiatric consultation or referral to a physician experienced in the use of medication is recommended. Frequent medication adjustments are ill-advised, and tapering of medications that have shorter half-lives (eg, paroxetine) is recommended. Obtaining serum levels rarely is necessary unless concerns arise about toxicity or compliance. Studies among adults suggest that the same doses used to treat MDD are efficacious for DD.
Tricyclic antidepressants (TCAs) are not considered a first-line treatment for children and adolescents who are depressed, but they may be helpful in treating youth who have comorbid attention-deficit/hyperactivity disorder, enuresis, and narcolepsy as well as for augmentation purposes.
In contrast to TCAs and monoamine oxidase inhibitors, SSRIs have a relatively safe adverse effects profile, are easily used (once daily), are suitable for long-term maintenance, and have a low lethality after overdose. Additional information on adverse effects, medication interactions, and the treatment of comorbid conditions is available in reviews of practice recommendations published by the American Academy of Child and Adolescent Psychiatry.
Electroconvulsive Therapy (ECT).
ECT can be a useful adjunct for individuals whose depression is severe or life-threatening, who have not responded to other treatments, who cannot take antidepressant medications, and who may have psychotic depression. The decision to use ECT must be made carefully and usually requires the recommendation of more than one psychiatrist as well as a substantial discussion with the child’s parent or guardian.
Continuation and Maintenance Treatment
Unless there are significant adverse effects, medication should be continued for 6 to 12 months if it is believed to help in the remission of depressive symptoms. The pharmacotherapy should be monitored monthly during this continuation phase. Psychotherapy is helpful during this phase to bolster coping skills and to address antecedents, stressors, and interpersonal conflicts that may have contributed to the onset of depression. Medication adherence also may be improved by psychotherapy.
Once the patient’s symptoms have remitted for 6 to 12 months, the maintenance phase of treatment may last from 1 year to indefinitely. The goals are to facilitate healthy development and to prevent relapse or recurrence. These may be accomplished through monthly or quarterly visits, depending on the severity and chronicity of the present episode, frequency of previous episodes, comorbid disorders, the patient’s motivation, and contextual factors (eg, support systems, family stress, and psychopathology).
Treatment of Related and Comorbid Disorders
The presence of comorbid conditions often predicts a poorer response to psychopharmacologic and psychosocial treatments. These conditions, such as anxiety, disruptive behavior, and substance use disorders, often persist after remission of the depressive symptoms and require targeted treatments. Because of time, cost, or the incompatibility of treatments, addressing all conditions simultaneously may be impossible. Hence, the clinician often must prioritize treatment goals and the sequence of interventions.
Variants of Depressive Disorders.
A depressive disorder may be “treatment-resistant” because of an inadequate dosage or duration of medication trial, inadequate duration or “fit” with a particular psychotherapy, poor treatment adherence, complicating comorbidity, undetected BD, chronic or severe life events, misdiagnosis, or mistreatment. Psychopharmacologic strategies to address treatment-resistant depression should be applied systematically in conjunction with family education and support and include optimization, switching, augmentation, or combination. Consultation with a psychiatrist always is advised with treatment-resistant cases.
If BD is present or is a possibility, a mood-stabilizing agent (eg, lithium carbonate, valproate, or carbamazepine) may be warranted, especially because antidepressants may induce mania in youths at risk for BD. Approximately 30% to 50% of adults experience modest antidepressant effects with mood stabilizers alone. Antidepressants may be useful adjuncts in such treatments. Psychotic depression may require a combination of antidepressants with antipsychotics or ECT. Neuroleptics should be tapered after psychotic symptoms remit due to the risk of tardive dyskinesia. Atypical antipsychotic medications may be preferred. However, the long-term effects of these medications have not been studied in youth.
Suicide And Suicidal Behavior
Epidemiology of Suicide
Suicide is the third leading cause of death among children and adolescents (National Center for Health Statistics, CDC, 2000). The suicide rate for ages 15 to 24 years is 11.1 per 100,000, which is much higher than the rate for youth between the ages of 5 and 14 years (0.8 per 100,000). The suicide rate for males in the 15- to 19-year age group is markedly higher than that for females (Table 3). Rates differ by racial and ethnic group. African-American youth have lower suicide rates than Caucasian youth, with the lowest adolescent suicide rate being that of African-American females. The highest suicide rate is that of Native American males.
|♦ Higher prevalence among females|
|—18% to 25% females|
|—11% to 14% males|
|♦ Higher prevalence among females|
|—4% to 6% males|
|Suicide (1999 Official USA Statistics)|
|♦ Higher prevalence among males|
|—13.3 per 100,000 (males 15 to 19 y)|
|—2.8 per 100,000 (females 15 to 19 y)|
Although many youth who report suicidal thoughts or attempt suicide do not become suicide victims, these categories overlap substantially. For instance, having frequent thoughts of suicide is the best predictor of suicide attempts, and most youth who attempt suicide report a history of suicidal ideation. Furthermore, greater severity of reported suicidal thoughts increases the likelihood of a suicide attempt within the next year. Approximately 35% to 45% of adolescents who complete suicide have a positive history of suicide attempt. The prevalences of both self-reported suicidal ideation and suicide attempts are higher for adolescent females than for adolescent males (Table 3).
Risk Factors for Suicide
Risk factors for completed suicide and suicidal behavior are similar in most respects. There are a few exceptions, however, such as the more specific relationship between availability of firearms and completed suicide. In this section, we review the primary risk factors for completed suicide (Table 4).
|History of Suicidality and Current Suicidality|
|▪ Suicidal urges, thoughts, plans|
|▪ Previous attempt (intent, lethality, precipitants, reasons)|
|▪ Exposure to suicide attempt/completion (friend, family, acquaintance)|
|▪ Depressive/Bipolar Disorder|
|▪ Alcohol/Substance Abuse|
|▪ Conduct Disorder|
|▪ Aggression, impulsivity|
|Family and Interpersonal Stress|
|▪ Parent psychopathology, substance abuse|
|▪ Physical/sexual abuse, violence, conflict|
|▪ Homosexual orientation|
|Availability of Means|
|▪ Toxic chemicals|
↵* Although less common among youth suicide victims, most psychiatric disorders (eg, schizophrenia, anxiety disorders) are associated with an increased risk of suicide.
Prior Suicide Attempt.
A history of prior suicidal behavior is the strongest predictor of future suicidal behavior. Nonlethal suicidal gestures or self-inflicted harm, which sometimes are thought to be manipulative or attention-seeking, should not be taken lightly. Youth often can be poor judges of lethality, and what is believed to be a gesture actually may be accompanied by significant suicidal intent. It also may result in substantial physical harm or even suicide because of an error in knowledge or judgment (eg, potential lethality of acetaminophen overdose).
Approximately 80% of youth who attempt suicide and 90% of youth suicide victims have histories of identifiable psychiatric or mental disorders. The most common types of psychopathology in these youth are depressive disorders, alcohol or substance abuse, conduct disorder or patterns of aggressive behavior, and anxiety disorders. Increased suicide risk is associated with conditions that often are refractory to treatment or present management problems. These include BD, a chronic depressive disorder comorbid with alcohol or substance abuse, and psychotic presentations.
Depressive disorders are linked with increased risk for suicidal ideation, suicide attempts, and completed suicides (Table 5). In fact, suicidal ideation and behavior are common and often unrelenting problems among youth who have depressive disorders. Eighty-five percent of depressed youth report significant suicidal ideation, and 32% of depressed youth report one or more suicide attempts prior to adulthood. Retrospective studies have found that about 50% of adolescent suicides involve the consumption of alcohol, which increases impulsivity, impaired judgment, and mood changes.
|♦ 85% of depressed youth report significant suicidal ideation, and 32% attempt suicide by late adolescence|
|♦ Past suicide attempt and current depressive disorder are strongest predictors of future suicide attempt|
|♦ Approximately 50% of adolescent male suicide victims and 66% of female suicide victims suffered from depressive disorder|
Environmental or family stress, especially a history of neglect or physical, emotional, or sexual abuse, are considered significant risk factors for suicidal behavior. Interpersonal conflict and loss (eg, fights, break-ups, deaths) also are risk factors. Additionally, hopelessness, impulsivity, aggressive behavior, and agitation are psychological characteristics associated with increased risk for suicidal behavior.
Gay, lesbian, and bisexual adolescents are at increased risk for suicidal behavior. Recent general population surveys indicate that approximately 42% of these youth experience suicidal ideation, and 28% have made one or more suicide attempts during the past year. Many of the risk factors in these youth are the same as those for heterosexual youth. Problems such as comorbid substance abuse and depression, however, are more common among youth who have a homosexual orientation. In addition, risk factors such as stigmatization and discrimination are specific to those who face negative attitudes within society.
The risk for depression, anxiety, and suicide increases when a youth knows someone who commits suicide. In these situations, intervention aimed at promoting grief and mourning and decreasing guilt, trauma, and social isolation as well as providing psychoeducational counseling aimed at decreasing identification with the suicidal behavior are recommended. Media coverage of suicide may spark suicide contagion. Clinicians are encouraged to advise reporters whenever possible to reduce excessive coverage and to advise parents and educators to discourage exposure of youth to such coverage.
Availability of the Means.
Firearms are found more commonly in the homes of suicide victims than in the homes of other youth, including those of psychiatrically hospitalized suicidal youth. The importance of restricting suicidal youth’s access to firearms is highlighted by documented associations between more restrictive gun control laws and decreases in suicide rates. Similarly, potentially lethal drugs (such as prescription or over-the-counter sedative drugs) either should be removed from the homes of potentially suicidal youth or monitored closely by parents and guardians.
Evidence suggests that if asked directly, adolescents will reveal suicidal preoccupations and previous suicidal behavior. Direct questions should address whether children or adolescents wish they were not alive, if they ever have thought about or tried to hurt themselves intentionally, if they ever have thought about or tried to kill themselves, and if they have or had such a plan in mind. It is important to understand that asking an adolescent about suicidal thoughts or behaviors will not “put such ideas into his or her head” or increase the risk for suicidal behavior. Follow-up inquiry regarding the intensity, chronicity, specificity, and recency of such thoughts is advised. Standardized self-report questionnaires, such as the Suicidal Ideation Questionnaire, may permit the youth to answer without direct verbalization, which can facilitate honesty. If endorsed, critical items related to intent or planning and items suggesting significant suicidality (in terms of chronicity, severity, or frequency) always should be followed up with direct inquiry. Other sources of information include reports from parents, teachers, or others who may have heard suicidal statements or witnessed behaviors such as giving away prized possessions. As with the assessment of depressive disorders, a comprehensive evaluation that incorporates input from the youth and parent or guardian is essential.
Management and Preventive Strategies for Suicidal Youth
A psychiatric inpatient or partial hospitalization program may be necessary for patients found to be at elevated suicide risk. Hospital stays generally are brief and emphasize safety, stabilization, evaluation, and aftercare recommendations. Suicide attempts (or plans) that have significant lethality and that include efforts taken to avoid detection indicate serious intent as well as knowledge and planning and should be taken extremely seriously. Furthermore, attention to safety requires consideration of the child’s home environment. Parents and caregivers should be advised to remove lethal agents, especially firearms and toxic medications, from the home. Self-injurious behaviors by young children should not be disregarded as accidental. For example, when a 6-year-old child ingests poisonous materials, it may not be accidental. Such behavior should be assessed carefully for associated mood or other disturbance.
No Suicide Contracts.
Verbal or written “no suicide” contracts are used in many settings. The patient is asked to agree not to attempt suicide. Furthermore, the patient is asked to agree to contact the clinician, parent, or other responsible adult if he or she feels a suicidal urge or experiences suicidal intent. Perspectives on these contracts have evolved over the past decade, with an increasing emphasis on using the contract as an assessment tool. The contract process may reveal current suicidal intent. It also provides information about the patient’s ability to identify, and willingness to turn to, helpful adults. It is useful to review what positive coping steps the youth and parent would take in the event of a suicidal crisis. This offers an opportunity for problem-solving and can counter the tendency of some youth and families to minimize or deny the risk of suicidal behavior. It should be noted, however, that research does not support the conclusion that such contracts prevent suicide; they are not substitutes for comprehensive case management.
When caring for a potentially suicidal youth, suicide risk factors, including suicidal thoughts, urges, and behaviors, are monitored at each session. Rules of thumb when working with suicidal youth include: 1) confirming next appointment times at each session, 2) following up on “no-shows,” and 3) providing information to the youth and parent or guardian about easily accessible 24-hour emergency services. Comprehensive case management includes psychoeducation and regular patient monitoring with guidelines for responding to crises/changes in functioning.
The population of suicidal youth is heterogeneous in terms of primary psychiatric disorder(s), comorbid conditions, personality traits, the presence of complicating psychosocial issues, developmental level, and demographic characteristics. Therefore, the treatment should be based on a comprehensive evaluation of psychopathology and, more generally, suicide risk and protective factors.
Hovey JD, King CA. The spectrum of suicidal behavior. In: Marsh DT, Fristad M, eds. Handbook of Serious Emotional Disturbance. New York, NY: John Wiley & Sons;2002:284– 303
- Copyright © 2003 by the American Academy of Pediatrics