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Mental Health
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A GP’s approach to
adolescent depression
Early symptoms of depression in adolescents can be difficult
to distinguish from ‘moodiness’, writes Mary Short
ACCORDING TO A RECENT STUDY from Brown University,
childhood depression often goes unrecognised, even by parents who have good communication with their children.
The markers for depression are the same for adults and
children alike but are expressed differently where specific
behaviour patterns may be different, and vary according to
the age and developmental level of the child. Children and
teenagers, not having the language skills, are often unable
to express their feelings as sadness or depression but are
more likely to be bored, angry, or just not happy. Children
who have blood relatives that suffer from depression, anxiety disorders and substance abuse disorders have a biologic
tendency towards depression, and are more likely to develop
clinical depression than children that do not have relatives
with these disorders.
Depression is a disorder that is defined by negative
thoughts and abnormal behaviour patterns and in clinical
practice (backed up by studies) the most common symptoms of depression reported in children and adolescents
were sadness, inability to feel pleasure, irritability, fatigue,
insomnia, lack of self-esteem and social withdrawal. Children are more likely than adolescents to suffer from physical
symptoms (eg. stomach aches and headaches), hallucinations, agitation and extreme fears. On the other hand,
adolescents showed more despairing thoughts, weight
changes and excessive daytime sleepiness.
The statistics on childhood and adolescent depression are
sobering. Studies indicate that one in five children has some
sort of mental, behavioural or emotional problem, and that
one in ten may have a serious emotional problem. It is
thought that approximately 200,000 children in Ireland
suffer from depression at any one time and 20,000 of these
will have depression of such severity that it will be disabling.
Childhood depression appears to be more common in boys
than in girls (about a five to one ratio, boys to girls) until
adolescence, when it becomes more common for girls than
boys (two to one ratio, girls to boys).
Among adolescents, one in eight may suffer from depression. Of all these children and adolescents struggling with
emotional and behavioural problems only 30% receive any
sort of intervention or treatment, the other 70% simply
struggle through the pain of mental illness or emotional turmoil, doing their best to make it to adulthood, according to
the US National Institute of Mental Health.
For the majority of children, depression is a recurring condition if left untreated. However, it is not known when
depression may recur or how severely. Depression that
remains untreated on average may last nine months and
take nine more months to fully resolve. The consequences
of untreated depression lead to an increased incidence of
depression in adulthood, involvement in the criminal justice
system, or in some cases, suicide. Suicide is the third leading cause of death among young people aged 15-24. Even
more shocking, it is the sixth leading cause of death among
children aged 5-14. The most troubling fact is that these
struggling teens often receive no counselling, therapy, or
medical intervention, even though the US National Institute
of Mental Health reports significant success with therapy
and less likelihood of relapse.
With treatment, the length of the depressive episode is
much shorter, and the child will recover more quickly. This
results in less disruption to the child’s life with a quicker
return to normality at home, with friends and at school, and
less interruption or slowing of the developmental process. It
is believed that treatment of depression will reduce the
likelihood of depression recurring, delays the return of symptoms and reduces the severity of symptoms overall. From a
statistical point of view, about 70% of children and adolescents will have another episode of depression within five
years of the first one.
Early symptoms of adolescent depression can be difficult
to diagnose because they appear to be a normal part of the
difficulties adolescents face. Melancholy and bad moods or
moodswings are a feature of adolescence and short periods
of ‘feeling down’ are common to everyone. Most people have
mornings when they don’t want to get out of bed, lack
enthusiasm for meeting friends, making that phone call or
going out.
These are normal enough features of adolescence. Mostly,
teenagers bounce back from those flat moods and continue
with their daily lives. Growing up is not easy and teenagers are
regularly pushing the boundaries. The reasons for depression
can vary from adolescent to adolescent. Often, depression is
multifactorial, triggered by different life events where adolescents do not have the coping skills to deal with them:
• Significant life events from death of a parent to breaking
up with a boyfriend or girlfriend, bullying or any event that
causes lack of self-esteem
• Earlier traumatic experiences such as abuse or incest
• Stress, especially if the adolescent lacks emotional support
• Hormonal/physical changes that occur during puberty
which cause new and unexpected emotions
• Medical conditions, eg. hypothyroidism
• Allergies – to wheat, sugar and dairy
• Nutritional deficiencies, eg. an amino acid imbalance or
vitamin deficiency
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• Genetics – family history of depression.
Successful treatment of childhood and adolescent depression requires interventions on several strategic fronts. A
thorough and accurate diagnostic evaluation of the child/
adolescent is important. School life and home life as well as
social life need evaluation as they may give pointers to the
cause and severity of the condition. Very frequently, school
or peer issues, poor parenting or problematic domestic
arrangements can lead to and/or perpetuate an environment
in which the child’s depression foments.
School modification and intervention, together with family
and home modification may be necessary to create an environment that fosters recovery while minimising the
disruption to the family and child’s lives.
Teenage moodiness is a normal part of adolescent development. Hormonal changes, academic and social challenges
escalate as children endeavour to create a distance from
their parents as part of the growing-up process. Even things
that seem minor to an adult can be major to a young person,
who does not have the life experience to put them into perspective or the coping skills that an adult has honed.
However, some adolescent behaviours or attitudes that are
annoying to adults are actually indications of depression.
Teenagers may use drugs or alcohol to self-medicate in the
way that depressed adults often do, they may develop eating
disorders, act out with aggressive or gloomy behaviour or
they may even self-mutilate.
Major depression limits an adolescent’s ability to function
normally. Depression may be indicated if an adolescent
experiences an unusual degree of the following symptoms:
• Changes in eating and sleeping habits (eating and sleeping too much or too little)
• Significant weight-gain or loss
• Missed school or poor school performance
• Withdrawal from friends and family
• Lack of interest in leisure activities/feeling that nothing is
worth the effort
• Indecision, lack of concentration or forgetfulness
• Feelings of worthlessness, guilt, or low self-esteem
• Overreaction to criticism, anxiety, irritability, anger, rage
• Frequent health complaints when no physical ailment
exists
• Drug/alcohol abuse, thoughts of death or suicide.
Prolonged low self-esteem with substance abuse can lead
to suicidal ideation. An alarming and increasing number of
adolescents attempt and succeed at suicide. As mentioned
before, suicide is now the third highest cause of death in
adolescents, and children as young as five have been
reported to have committed suicide. It is also probable that
suicide statistics for adolescents and young people are
underreported, as they might overlook those whose reckless
or dangerous behaviour resulted in death, eg. there have
been suggestions in the past that the lone driver involved in
an accident may have been a suicide or there are those in
which the cause can not be definitely identified.
Isolation is a large part of depression, but sharing the
emotional turmoil of confusion, sadness, loneliness and
shame decreases the intensity of these emotions and opens
the way for real communication. Parents who show their
children that disagreements and painful feelings can safely
be expressed – and that they can be resolved – make it safe
for their children to open up to them.
Depression is commonly treated with therapy or with therapy and medication. A combination of approaches is usually
most effective:
• Cognitive behavioral therapy focuses on the causes of the
depression and helps change negative thought patterns
• Group therapy is often very helpful for adolescents
because it breaks down the feelings of isolation that many
adolescents experience
• Family therapy as an adjunct to individual therapy can
address patterns of communication and can help the
teenager feel that others share the responsibility for what
happens in the family
• Physical exercise causes the brain’s chemistry to create
more endorphins and serotonin, which improve mood
• Creative expression through drama, art or music
• Medication for depression should be used with great caution, and only under careful supervision. Recent studies
by both the UK government and the FDA have led to warnings that not all psychiatric drugs may be appropriate for
teenagers and children. This is best prescribed through
consultant clinics
• Hospitalisation may be necessary in situations where an
adolescent needs constant observation and care to prevent
self-destructive behavior. Hospital adolescent treatment
programs usually include individual, group and family
counselling as well as medications.
Mary Short is in practice in Dublin
References on request