Depression in Youth: A look back to the futureOctober 26th, 2018
As Depression Awareness Month approaches the end of October, so does the final article in my series Depression Through the Lifespan. We have taken a retrograde journey starting from geriatric depression, to middle age and young adults. Now, we will explore depression in the pediatric and adolescent population, where it all begins for many patients.
The prevalence of depression is estimated to be 2.8 percent in children younger than 13 years and 5.6 percent in adolescents 13 to 18 years of age. Approximately 8% of all teenagers have met criteria for depression this year. Approximately 60 percent of adolescents with depression have recurrences throughout adulthood.
As a child and adolescent psychiatrist, I have evaluated and treated this age group and have come to the conclusion that one of the best career decisions I ever made was choosing to continue my fellowship training and subspecialize in taking care of youth. The perspective it has afforded me has made me a better psychiatrist; I have no doubt. As advanced as we are, we have no access to a time machine to intervene as a means of prevention. To have an opportunity to intervene on the progression of depression in children is invaluable and life-saving, though I am not only referring to life as it pertains to preventing suicide. I am also taking note of how early intervention can significantly improve the quality-of-life for the future years of these young patients.
In children and adolescents, depression can adversely affect school performance, relationships with parents and peers, and other everyday functions. What’s more, depressed adolescents are more likely to engage in risky behaviors such as promiscuity or drug use. Unfortunately, these problems created by depression can perpetuate and augment its reasons, creating a vicious cycle. In addition, not only can I have an impact on the lives of the children and teenagers I care for, but their parents’ lives as well. As a pediatric psychiatrist, I am well aware of the fact I am not only treating the identified patient but the family system as well.
As a parent myself, I fully empathize with the worry that comes as an occupational hazard of parenthood. There is no escaping it. Therefore, I completely understand the level of worry, even anxiety that can be provoked when taking our children to see the doctor for an issue, any issue. We never want to see our children in pain or struggling. However, when it comes to mental health, this is a different kind of pain and suffering our children may be experiencing. When our child has a fever, we can wrap our brains around that process. My child’s body is fighting off some kind of infection, and the doctor will find the source of the infection and treat it with a medication. This makes sense. However, without a fever to measure, without a pain source my child can point to when asked “where does it hurt,” parents can have a difficult time understanding what to do. When my child is crying uncontrollably, or is failing most of their classes and dropped out of all extracurricular activities, or is hibernating in their room, isolative from family, what thermometer can I use? It is especially more difficult if the parents have never experienced depression themselves, but here is where it is so important to recognize the signs of depression brewing in the pediatric population. The presentation of depression in youth can be very different from an adult presentation.
Depressed mood, such as feeling low, down, or sad, most of the time, is a key symptom of depression. This depressed mood can manifest as perceiving others as antagonistic or uncaring, ruminating about real or potentially unpleasant circumstances, maintaining a gloomy or hopeless outlook, believing that everything is “unfair,” or feeling helpless or that they disappoint others. However, minors sometimes lack the emotional and intellectual maturity to recognize that they are dealing with depression. Instead, it’s not unusual for them to express themselves with an irritable mood, which can manifest as feeling “annoyed,” “grouchy,” or “bothered” by everything and everyone. Rather than expressing sadness, depressed children and adolescents may be negative and argumentative, and instigate fights as a means to convey their emotional distress. They sometimes have a low frustration tolerance and are sometimes intolerant of frustration and respond to minor provocations with angry outbursts. As a coping mechanism, adolescents sometimes seek out activities and experiences to temporarily lift their mood. Examples of these activities include time spent with friends, thrill-seeking, promiscuity, and drug use.
Most adolescents, regardless of whether they are depressed, are invested in their friends, but in the context of depression, the need for social connection sometimes becomes much more intense and urgent. In part, that may be because depressed adolescents, particularly girls, seek out and commiserate with other depressed peers about their symptoms, which can reinforce the problem. Children and adolescents with depression lose interest in or no longer feel pleasure doing the things they used to enjoy. The medical term for this is anhedonia. Hobbies, interests, and even loved ones lose their appeal, such that depressed children or adolescents may describe experiences as “boring,” “stupid,” or “uninteresting.” They may withdraw from or lose interest in friends.
In children, a decrease in appetite may manifest with failure to gain weight as expected, rather than weight loss as would be noted in adults. Depression can cause children and adolescents to sleep too much or too little or have odd patterns of sleep. For instance, those with depression might have trouble getting to sleep, wake in the middle of the night and have trouble getting back to sleep, or wake too early and be unable to get back to sleep. Some may even have flipped sleep cycles, sleeping during the day and awake at night. Regardless of when they sleep, many children and adolescents with depression say they do not feel rested and have a hard time getting out of bed in the morning. Youth with depression often feel exhausted and listless. They sometimes need to rest during the day. They can have trouble initiating or completing tasks. This listlessness can cause conflicts with parents if parents attribute lack of energy and motivation to laziness, an oppositional attitude, or ignoring their responsibilities.
Depressed children and adolescents often feel inadequate, inferior, worthless, or like a failure. This symptom can be difficult to evaluate, because they aren’t necessarily willing to admit these feelings. Children and adolescents who are struggling with feelings of worthlessness or guilt may be excessively self-critical of their accomplishments or have trouble identifying positive self-attributes. They may be dissatisfied with several aspects of themselves or can be envious or be preoccupied with the success of others. Often, they blame themselves for events that are not their fault, and they believe they deserve to be punished for things that are not their fault. A pediatric patient with depression can be unwilling to try things out in the conviction that they will fail, often predicting a negative outcome. In other words, their self-esteem takes a major hit, which parents will typically note as a change in their child’s personality.
Taking a thorough history from the patient and the parents is so important. Depression is highly genetically driven, inherited within families. It is imperative to get a detailed family history for two main reasons; one, it helps guide me as it pertains to treatment options and prognosis. The other reason is to explain to the child and their parents when they ask me “why do I feel this way?” My answer is “because you can’t run away from your genes, but you for sure can do something about it.” It is important to relay to the patient and their parents that the child is not failing in school because they are lazy, and they are not isolating themselves to their bedroom because he or she is just “moody.” Depression is a specific constellation of symptoms and is not a choice the child is making; it is a condition but a treatable one. One piece remains a constant at any age; intervention is the key, the earlier the better.
Despite the significant burden of depression on children and adolescents, only a minority receives any treatment. As a subspecialist, I am not typically the first provider to evaluate a child for depression. Our first line of defense are still the primary care providers (PCPs). PCPs are well-positioned to improve the recognition and treatment of depression among children and adolescents, given the frequency with which this population sees their PCPs and their comfort in discussing health behavior concerns with their clinicians. Interventions delivered to depressed adolescents by PCPs and within the primary care setting have demonstrated effectiveness. However, many PCPs report significant barriers to identifying and, particularly, to treating pediatric depression in their practices.
PCPs have cited the Food and Drug Administration’s 2004 black box warning on the safety and efficacy of antidepressants for children and adolescents, as an impediment to treating pediatric depression. I can recall this significant event and turning point during my general psychiatry residency training. Almost immediately after this report became a public warning, pediatric patients were pulled off their antidepressant medications, whether they were beneficial or not. Subsequently, the amount of prescriptions for antidepressants, whether prescribed by PCPs or specialists decreased significantly. In a study several years later, it was noted that immediately following the prescription rate declining, the suicide rate increased as a direct result. Lesson learned: depression treatment saves lives. Published in 2007, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC), a North American collaborative to develop guidelines for the management of adolescent depression in primary care was created by researchers and clinicians from the USA and Canada in response to the gap in clinical guidance for PCPs.
Treatment for this age population can come in other forms besides medication. Evidence-based psychotherapy, such as cognitive behavioral therapy and family therapy, has been shown to be very effective and imperative in producing the best outcomes for the pediatric patients. Kids need an outlet to talk about their thoughts and feelings and struggles, and it cannot and sometimes should not always be with a parent. Whether it starts with a friend, a teacher, or a guidance counselor, they need to reach out for help. The negative stigma of depression has been a significant barrier to children and teenagers and even adult parents getting the medical attention they need. As I noted in previous blogs, this has been steadily improving, but we are not there yet. Perhaps if parents did not assume that medication was the only treatment option, they would be more apt to report their child’s symptoms to a professional.
Besides talk therapy, new advancements in non-medication interventions for depression are currently under investigation and are in clinical trials to prove safety and efficacy. Repetitive Transcranial Magnetic Stimulation (rTMS) is in the phase of clinical trials to establish efficacy, as safety has already been established for treatment of adolescent depression. Regardless of the nature or form of the intervention, intervention must happen. Depression simply does not disappear and never come back, in fact, quite the opposite. Depression is more likely to recur repeatedly if left untreated, and symptoms can worsen with each episode, so imagine the level of severity depression can reach if episodes began in childhood. Early intervention is the key. We do not have a time machine as a means to prevent depression, but we have many valid and helpful tools and treatment options to help our youth and prevent them from having a lifetime of struggles impacting several spheres of their lives.
I feel very blessed to have the knowledge and training needed to bring immediate relief for our depressed children, but also provide prolonged benefit and prevent a potential lifetime of unnecessary suffering. Until we invent a time machine, my hope is that if we can have a positive impact early in the life of a human being, we can then alter the future course and shift the rising statistics of depression through the lifespan, giving people at any age an opportunity to live a life free of depression.