Depression in childhood and adolescence

Many people misunderstand or fail to recognize depression in youths. Educators and parents sometimes think a child is not depressed simply because they do not appear sad, but irritability is also a key sign of depression among youth, according to the text-revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, 2022), published by the American Psychiatric Association (APA). Furthermore, school administrators and educators are more likely to refer children to school or clinical psychologists when they observe behavior problems, inattention, or academic problems, whereas internal emotions are harder to recognize and ostensibly do not cause as many problems for those around them. The good news is that there is increasing evidence that depression can be accurately identified and effectively treated or even prevented in youths.

Background

Along with the fields of psychology and medicine as a whole, scientific research in the realm of child and adolescent depression has advanced significantly since the mid-twentieth century. The dominant first-line treatment for childhood and adolescent depression was antidepressant medication until 2004, when the US Food and Drug Administration (FDA) issued a black-box warning for antidepressants for children and adolescents, citing research indicating that antidepressants may increase the risk of suicidal thinking, feeling, and behavior among youths. This decision was based on meta-analyses of 372 clinical trials of antidepressants, which showed that while the rate of suicidal thinking or behavior in patients who took antidepressants was twice as high (4 percent) as in patients who received a placebo (2 percent), this difference was only significant among patients under age eighteen. Many medical experts and practitioners objected to the FDA's decision, fearing that it would have a "chilling effect" by discouraging patients from seeking necessary help for depression and doctors from prescribing antidepressants when necessary. In response, the FDA issued an expanded black-box warning that among patients of all ages with major depressive disorder (MDD), suicidal ideation and behavior can occur regardless of antidepressant use.

A review published by Richard A. Friedman in the New England Journal of Medicine in 2014—ten years after the first black-box warning—cited a study showing that rates of antidepressant use reduced significantly within two years of the 2004 warning, not just among youths (31.0 percent relative reduction) but also among young adults between the ages of eighteen and twenty-four (24.3 percent relative reduction) and among adults older than twenty-four (14.5 percent relative reduction), and that while the use rate among adolescents rebounded slightly in 2008, rates remained lower than would be expected among all age groups. Another study showed that between 2003 and 2005, the prescription rate for selective serotonin reuptake inhibitors (SSRIs) decreased by about 20 percent, while the rate of adults with depression who were not receiving antidepressants increased from 20 percent to 30 percent. In short, a warning aimed at curtailing antidepressant use among children and adolescents had the unintended effect of curbing use among all age groups. The rates of new depression diagnoses and treatment for depression decreased significantly as well, perhaps because the reduction in antidepressant prescriptions was not accompanied by a concomitant increase in the use of alternative treatments for depression, such as psychotherapy or alternative types of drugs. In addition, the rate of psychotropic drug poisonings, which one study cited by Friedman uses as "a proxy measure for suicide attempts," increased significantly in the second year after the first warning was issued, by 21.7 percent among adolescents and 33.7 percent among young adults. Friedman notes that there is no direct evidence of a causal link between the black-box warning and the subsequent changes in antidepressant prescription, depression diagnosis, and attempted suicide rates, but that it is vitally important for primary care providers to be aware that whatever risks may be associated with antidepressant use, the risks of allowing depression to go untreated are far greater.

Aside from antidepressants, one of the most effective psychosocial treatments for depression is cognitive behavior therapy (CBT), which emerged in the late twentieth century as a viable intervention for depression and anxiety. Prior to CBT, many psychologists relied on behavioral therapy, which has effective components such as positive activity scheduling, but CBT is an improvement over traditional behavioral therapy because it addresses the negative and irrational thought patterns that are thought to characterize depression. Interpersonal therapy (IPT) is also an evidence-based intervention for depression among youth and focuses more extensively on family and social relationships.

Psychotherapy modalities for youth were often first developed for adults and then attempted with youth. In other words, the therapies were typically not developed with child and adolescent development in mind. Thus, in order to be successful with youth, researchers and therapists had to adapt the therapeutic modalities. There are now various psychological techniques designed for use in psychotherapy for children. Younger children or adolescents with limited verbal abilities may also respond quite well to high-quality play therapy mixed with parent and teacher psychological consultation that aims to improve the classroom and home environments.

Overview

In response to the changes in the diagnosis and treatment of depression following the FDA's warning, the APA and the American Academy of Child and Adolescent Psychiatry (AACAP) issued updated guidelines in 2010 for the treatment of depression in children and adolescents. Citing one 2004 study that found adolescents treated for depression with the antidepressant fluoxetine (trade name Prozac) had higher rates of suicidal thinking and behavior than adolescents who were treated with CBT or a combination of medication and CBT, the guidelines note that "all three treatment approaches reduced the frequency of suicidal thinking and behavior" compared to a pretreatment baseline, and that even though the fluoxetine treatment was initially associated with an increase in suicidal thinking and behavior compared to the other two treatments, three months into the treatment "the number of young people experiencing such thoughts and behaviors dropped substantially."

Accordingly, AACAP's website, which had previously recommended education, supportive treatment, and case management as the initial treatment choices for depression, now recommends that "when possible, treatment for childhood depression should include both psychotherapy and medication. In milder forms of depression, it is reasonable to start with a psychotherapy, but treatment with a medication and psychotherapy should be considered for moderate to severe forms of major depression." It also notes that while antidepressants are associated with a "small increase in thoughts of suicide" in youths, there is "no clear evidence" that antidepressants increase the actual risk of suicide, and that "for moderate to severe depression, the potential benefits from medication treatment seem to outweigh the potential risks," provided that the use of medication and its potential side effects are closely monitored.

Psychotherapy is another important treatment for depression in youths, whether or not it is supplemented by medication. Interpersonal therapy and CBT have been shown to be among the best psychotherapeutic options for the treatment of depression in children and adolescents. In addition, the positive psychology movement that gained momentum in the 1990s has contributed to the prevention and treatment of depression. Positive psychology researchers have discovered many paths for happiness among youth, such as gratitude, intrinsic motivation to learn, mindfulness, academic success, hope, altruism, open communication, positive expectations, and positive peer relationships. There are many preventive interventions being developed that can elevate these positive factors and at the same time decrease symptoms of depression.

There are now assessment systems designed to identify depression and anxiety early on, before they reach a clinical level. This is important because children and adults who experience one clinically significant depressive episode are more likely to experience a second. Once identified, children with subclinical levels of depression can be provided with group therapy or positive psychological interventions. Since negative parenting practices (lacking warmth, being controlling) contribute to the development of depression, parents can also be involved in interventions and benefit from education. Children that do not improve after receiving the group-based interventions can receive individual counseling, preferably with highly research-based therapies such as CBT or IPT. If they still do not improve, based on data collected and graphed weekly, they could be referred to a physician, such as a psychiatrist.

Natural interventions also hold the potential to reduce depression among youth, such as a rigorous exercise regimen. Since there are multiple ways to prevent and treat depression among youth that are underutilized, it is important for physicians, psychologists, parents, policymakers, educators, and society to be well informed about the research in this realm.

During the coronavirus (COVID-19) pandemic, which began to spread around the globe in early 2020, rates of depression and anxiety in youth skyrocketed globally due to increased social restrictions, isolation during school closures and lockdowns, deaths of relatives, economic instability, and uncertainty. According to one US national poll, nearly 50 percent of American parents reported their teens showed signs of new or worsening mental health since the beginning of the pandemic in March 2020. The results of that poll also indicated that the pandemic negatively affected teen girls more than teen boys. In addition to traditional treatments such as psychotherapy and medication, experts suggested strategies including relaxing family rules, encouraging healthy sleep habits, and using online programs to improve mental health during the pandemic.

Bibliography

Abela, John R. Z., and Benjamin L. Hankin, editors. Handbook of Depression in Children and Adolescents. Guilford Press, 2008.

Binagwaho, Agnes, and Joyeuse Senga. "Children and Adolescent Mental Health in a Time of COVID-19: A Forgotten Priority." Annals of Global Health, vol. 87, no. 1, 2021, p. 57, doi:10.5334/aogh.3330. Accessed 12 July 2024.

Birmaher, Boris, et al. “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders.” Journal of the American Academy of Child & Adolescent Psychiatry, vol. 46, no. 11, 2007, pp. 1503–26.

Depression: Parents' Medication Guide, American Psychiatric Association and American Academy of Child and Adolescent Psychiatry, 2018, www.aacap.org/App‗Themes/AACAP/docs/resource‗centers/resources/med‗guides/DepressionGuide-web.pdf. Accessed 12 July 2024.

"Depression Resource Center." American Academy of Child & Adolescent Psychiatry, Oct. 2019, www.aacap.org/AACAP/Families‗and‗Youth/Resource‗Centers/Depression‗Resource‗Center/Depression‗Resource‗Center.aspx. Accessed 12 July 2024.

Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. 5th ed., Text Revision, American Psychiatric Association, 2022.

Friedman, Richard A. "Antidepressants' Black-Box Warning—10 Years Later." The New England Journal of Medicine, vol. 371, no. 18, pp. 1666–68, doi:10.1056/NEJMp1408480. Accessed 12 July 2024.

Froiland, John Mark. “Parental Autonomy Support and Student Learning Goals: A Preliminary Examination of an Intrinsic Motivation Intervention.” Child & Youth Care Forum, vol. 40, no. 2, 2011, pp. 135–49. Academic Search Complete, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=59459974&site=ehost-live. Accessed 12 July 2024.

Froiland, John Mark. “Response to Intervention as a Vehicle for Powerful Mental Health Interventions in the Schools.” Contemporary School Psychology, vol. 15, no. 1, 2011, pp. 35–42. Education Source, search.ebscohost.com/login.aspx?direct=true&db=eue&AN=63010120&site=ehost-live. Accessed 12 July 2024.

Froiland, John Mark, et al. “Intrinsic Motivation to Learn: The Nexus between Psychological Health and Academic Success.” Contemporary School Psychology, vol. 16, no. 1, 2012, pp. 91–100. Education Source, search.ebscohost.com/login.aspx?direct=true&db=eue&AN=87745656&site=ehost-live. Accessed 12 July 2024.

Goldman, Stuart J., and Frances J. Wren, editors. Child and Adolescent Depression. Harsh K. Trivedi, consulting editor. Child and Adolescent Psychiatric Clinics of North America, vol. 21, no. 2, 2012, pp. 217–455.

Hicks, Tony. "How COVID-19 Pandemic Has Affected the Mental Health of Teens." Healthline, 6 Apr. 2022, www.healthline.com/health-news/how-covid-19-has-affected-the-mental-health-of-teens. Accessed 12 July 2024.

Huberty, Thomas J. Anxiety and Depression in Children and Adolescents: Assessment, Intervention, and Prevention. Springer, 2012.

Leon, Andrew C., et al. “Antidepressants and Risks of Suicide and Suicide Attempts: A 27-Year Observational Study.” Journal of Clinical Psychiatry, vol. 72, no. 5, 2011, pp. 580–86.

Sburlati, Elizabeth S., et al., editors. Evidence-Based CBT for Anxiety and Depression in Children and Adolescence: A Competencies-Based Approach. Wiley-Blackwell, 2014.

Springer, David W., et al., editors. Treatment of Depression in Adolescents and Adults. John Wiley & Sons, 2011.