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Depressive Disorders
by Michael Torres, Psy.D. and Jane Brooks, Ph.D.
Kaiser Permanente Department of Child and Adolescent Psychiatry, Hayward
What is Depression?
Depression is a medical condition just like diabetes, high blood pressure, and heart disease, that affects a person's behavior, feelings, thoughts, and body, and can be improved with appropriate treatment. This disorder is not caused by a personality flaw, laziness, or lack of will power. Depression affects people of all races and ages, and all social, economic, and educational backgrounds. However, women, the elderly, and teenagers have a higher risk of depression.
Teenagers are known for being tempermental and moody. The rapid and frequent mood changes they experience are usually in response to stress brought about by their physical, psychological, and social development. The moodiness shown by many adolescents is usually quite easy to distinguish from a clinical depression. The typical teenager undergoes many mood changes throughout the day. When a teenager has a Depressive Disorder, or what we call "clinical depression," it is more that just being "down" or "blue." It is an illness with a well-defined set of symptoms, distinct from the brief feelings of unhappiness or dissatisfaction with life that we all experience from time to time. For depression to be diagnosed, the symptoms have to be present 2 or 3 days every week for a period of at least two weeks.
The following statements illustrate the kind of feelings that may be expreienced by depressed adolescents and those around them:
The Adolescent
"Nothing seemed to matter. Nothing I did or other people tried to do for me seemed to matter. Just being alive seemed useless and painful."
"I was so down, I didn't think anyone wanted to be around me. So I stopped going out with my friends, and I shut myself off from my family."
"When my parents tried to talk to me, I could hardly find the energy to be pleasant and talk back to them. Other times I would get upset and start yelling for no good reason."
Those around them
"Why don't you try to cheer up? Think positive."
"Don't dwell on things, just snap out of it."
"At first I didn't really want to hear that my child had a mental illness. but in my heart I knew that something wasn't right."
Depression is a disorder of mood and can become a persisitent emotion that colors one's entire outlook on life. For many teenagers, depression is also accompanied by sudden changes in behavior that ranges from excessive passivity to agressive acting out. There are different types of depressive disorders depending on the duration and severity of symptoms:
Major Depressive Disorder
This type is characterized by symptoms that:
Begin suddenly, possibly is response to a major stresser, crisis, or change
Are so severe that they interfere with normal functioning
May continue for months or years, or return after a period of remission, if not treated
Dysthymic Disorder, also known as "Minor Depression"
This type of depression is characterized by:
A long lasting state of mild depression. People with this illness feel "down" much of the time
An ability to function fairly well on a daily basis, but over time their work and relationships may be seriously affected
A sence of feeling neither happy nor sad
A sence of not functioning at "full steam."
Basic Characteristics of the depressive disorders:
a prolonged period of sad mood
loss of interest
loss of pleasure in all or most activities
an increase or decrease in appetite
significant weight gain or loss
increased time spent sleeping (especially during the day) or inability to sleep at night despite feeling tired (insomnia)
being very slowed down
neglecting responsibilities and appearance
being jittery or restless
feeling irritable, cranky, or keyed up
lack of energy, or feeling tired almost all of the time
frequent feelings of boredom
feelings of hopelessness
feelings of lonliness or emptiness
feelings of worthlessness or exaggerated feelings of guilt that are not based on a specific situation
social withdrawal and isolation, spending a lot of time alone
feeling tense or worrying a lot
crying a lot
frequent physical complaints such as aches, pains, or poor digestion
lack of mental energy that may result in difficulty thinking clearly or concentrating
recurrent thoughts of death, dying, or suicide, or making a try at suicide
self-destructive behavior such as lying, stealing, fighting, skipping classes, or running away from home in order to aviod facing their feelings
Depressive disorders may be episodic, meaning they occur more than once, or at intervals during a person's lifetime. This may make a teen seem quite moody for a few weeks or months, with the mood improving for a time before worsening again. Depression can also be chronic, meaning it seems to go on for years without a break. Either of these may require long term maintenance of medication in order to aviod disabling symptoms or relapses of the symptoms of depression.
Occasionally, depressive disorders may present with only a single episode, which still may require continuing treatment for up to a year after the symptoms have been controlled, to allow that episode time to resolve before medication is stopped.
Who is a greatest risk for developing a depressive disorder?
As mentioned earlier, major depression is an illness, like heart disease or diabetes. It's caused by chemical imbalences that can result from several possible factors including genetics, stress, medical conditions like thyroid problems, and medication or drug side effects. However, some teenagers are more likely to develop a depressive disorder than others. Those at special risk include:
Those with a family history of depressive disorder
For many families, genetics may be a major risk factor for depression. Any family may carry a genetic vulnerability in their bodies to medical conditions. Examples include high blood pressure, heart disease, cancer, diabetes, migraine headaches, and high cholesterol, which may tend to occur frequently in certain families. The same has been found to be true for the various chemical imbalances that may lead to psychiatric disorders such as Major Depressive Disorder, Bipolar Disorders, Schizophrenia, and anxiety disorders.
Studies have shown that a child who has one depressed parent has a 1 in 4 chance of suffering depression, while a child with two depressed parents has a better than 1 in 2 chance of having depression at some point in their lives. This compares to a rate of 1 in 10 to 20 persons around the world having a depressive illness during their lifetimes. Sometimes parents may not have realized that they themselves have been suffering from a depression because the symptoms may have been moderate and very long lasting. Thus, they may have been able to function reasonably well, but they seldom feel really happy or content with their lives. Also, because depression tends to run in families, these adults may have just come to accept that it is normal to feel this way.
Those who are under significant stress at home due to the death of a loved one, parents' marital conflict, divorce, relocation, or substance abuse in the family
Those dealing with a particular stressor such as breaking up with someone, losing a pet, getting sick or hurt, conflict with a peer group, or academic problems due to learning disablities.
Those who have a chronic or serious illness
Those suffering from other psychiatric problems such as anxiety or an eating disorder
Those with a history of abusing drugs and/or alcohol
Depression may have been present before using the drug or alcohol, which may have been used by the teen to attempt to deal with their feelings. At other times, drug or alcohol use actually create the symptoms of depression. In that case, it normally takes 30 to 45 days after the drug or alcohol is stopped for the nerve cell components to be regenerated by the brain and the depression to abate. If drug or alcohol abuse appears to play a major factor in the depression, treatment for substance abuse should take place before treatment for the depression itself.
What you should know about teen suicide
Suicide is the third leading cause of death among teenagers. Many parents are led to believe, by misleading information, that suicide attempts are just a way for teens to get attention and that the best approach would be to ignore the behavior. This attitude could prove deadly to your child. Some adolescents do attempt suicide in order to get attention, but most it is to call attention to their problems and struggles. A suicide attempt is often a cry for help, an indication that a problem exists, and it should not be minimized or ignored.
Adolescents may attempt suicide for many reasons. Sometimes the actual event that triggered the suicide attempt may seem trivial and unimportant to adults: such as failure to receive an invitation to a party, an argument with a parent, best friend, boy-or-girlfriend, or an unexpected poor grade on a test. Whatever the reason, suicide is not a normal response to distress and those who attempt to take their own lives must get appropriate professional attention. Without adequate treatment some teenagers may make multiple attempts until they succeed.
If you are worried that your child may be feeling suicidal, don't be afraid to apporach him or her and ask about their feelings and intentions. Mentioning your concerns about suicide won't increase the likelihood of your child acting in a self-destructive manner.
Warning Signs of Suicide
Radical personality change: a gregarious teen becomes withdrawn or a shy child becomes extremely outgoing
Disregard for appearance: a teen who is normally attentive to how he or she looks suddenly begins to neglect his or her grooming, hygiene, and clothing
Withdrawal from family and friends
Giving away prized possessions and putting afairs in order
Preoccupation with death or morbid themes, including music, drawings, poems, and essays
Overy or veiled suicide threats: "I won't be around much longer," "They'd be better off without me," or "I wish I were dead."
Prior suicide attempts
Acquisition of a means to kill themselves (rope, guns, hoses, stockpiles of medicines)
Noticible changes in eating or sleeping habits
Unexplained or unusually severe violent or rebellious behavior
Running away
Persistent boredom and/or difficulty concentrating or studying
Drug and/or alcohol use
Unexplained decline in the quality of schoolwork, or academic failure
Increased accidents or multiple physical complaints with no medical basis
How does depression affect adolescent development?
Depression can interfere with an adolescent's development and ability to achieve despite his or her potential. Here are some ways in which depression negatively interferes with an adolescent's normal and healthy development:
A depressed child has trouble taking initiative, becoming independent, developing competence, and establishing an identity. Adolescents must learn to think and make decisions on their own. However, because of the cognitive deficits, feelings of insecurity, worthlessness, etc., depressed teens may become more emotionally dependent upon their parents and have difficulty moving ahead on their own.
Depressed adolescents tend to become withdrawn and socialy isolated, or begin to engage in conflictual interactions with their peer group. This distancing form their peers may have a very negative impact on their development since the peer group is a major source of acceptance and support for teens, and plays a major role in helping them to develop their own identity and achieve independent functionaing.
Usually, it is not until adolescents find relief from their depression that they will be able to resume normal development.
What to do about depression?
As mentioned ealier, occasional periods of low mood is part of adolescents' normal emotional experience. There factors are helpful in distinguishing between normal low mood and a Major Depressive Disorder:
Degree (how much?)
Pervasiveness (how deep?)
Duration (how long?)
Even though, after several months, depressive symptoms can go away by themselves, there are several compeling reasons to persue active treatment for this condition:
Early intervention can prevent the disorder from becoming more severe or chronic
Without treatment, depression is more likely to continue or to come back
Earlier treatment usually leads to faster recovery
Thoughts of suicide are common for people experiencing a depressive episode, and the risk of suicide increases for people who do not seek professional help and who experience frequent relapses
When untreated, depression can become severe enough to cause teenagers to be unable to function effectively in their daily lives
Despite the availablity of effective treatment, this disorder often is ignored or untreated because people have difficult recognizing the symptoms, are afraid to appear "weak," or are too depressed to take appropriate action. Overall, 80 to 90% of people suffering from a depressive disorder are successfully helped by active treatment.
Depending on the severity of symptoms, treatment may include individual and/or group therapy as well as medications. For most cases of major depression, a combination of psychotherapy and antidepressive medication has been shown to be the most effective treatment approach. When depression fails to improve with psychotherapy alone, treatment with antidepressive medication is usually recommended.
Treating Depression with Medication
Antidepressants can improve a depressed teenager's mood and relieve symptoms by altering the chemical balance in the brain back toward a healthier state. This restoration usually is reflected in a reduction in depressive symptoms after 4 to 6 weeks, and sometimes longer. A variety of medication types such as the Tricyclic Antidepressants {TCA} (Elavil, Norpramin, Pamelor, Tofranil) and Monoamine Oxidase Inhibitors {MAOI} (Nardil or Parnate) have been used to help relieve the symptoms of depression for decades. The newer antidepressants, such as the Selective Serotonin Reuptate Inhibitors {SSRI} (Prozac, Luvox, Paxil, Zoloft, Celexa) are the first-line (meaning we use these medicines before trying others) medications for treating depression in children and teens because they are safer overall and have fewer side effects. Other new or atypical antidepressants such as Wellbutrin, Serzone, Effexor, and Remeron may also be used. Antidepressant medications are not addictive and do not change a person's personality. Even though they are not habit-forming, their use must be monitored by a trained physician to ensure maximum effectiveness and minimum side effects. It may take some time until the dose of the specific medication or combination of medications can be found that works the best for an individual. It's important not to get discouraged to early, because the medicines must be given enough time to start to help and work properly.
Taking effective medication also has been shown to improve the effectiveness of Psychotherapy, which is most effective after the acute stage of the depressive illness has been stabilized. Treatment with antidepressants is usully continued for at least 6 to 12 months after the symptoms of depression have been fully relieved. Stopping too soon runs a higher risk that the depressive symptoms will come back as the effect of the medication is lost. After enough time has passed, the medication may be tappered down slowly under the suppervision of the prescribing physician who will monitor for any signs of recurrance. For those who have had multiple episodes of depression, staying on the medication indefinitely may significantly reduce the likelihood of an additional depressive episode.
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