Psychiatrists, other mental health professionals, pediatricians and educators are increasingly identifying the problem of depression among children and adolescents. Though major depressive disorder in preschool-age is rare and is estimated to be about 0.3%, the prevalence among school-age children is about 2%, and rises to 5% among adolescents. The rates are much higher in a clinical setting – up to 10% of hospitalised children, and 20% of such adolescents, suffer from depression. Suicide is a known complication of depression, and is the fourth leading cause of death in children between the ages of 10 and 15 years, and the third leading cause of death among adolescents. Early recognition and treatment of this disease is of paramount importance, as depressive disorders are known to recur. In fact, major depression among children could predict a serious, relapsing disorder, with lingering social impairment and a high risk of suicide. If not treated successfully, depression can manifest in the form of poor academic achievement, delayed psychosocial development, substance abuse and suicide. Thankfully, the ‘completed’ suicide is rare among children suffering from depression, as they have limited ability to plan and carry out a lethal attempt.
Unlike adults, children are not able to really communicate about a sadness of mood or a loss of interest or pleasure, the core symptoms of depression. The developmental level of the child appears to influence the expression of these mood symptoms. Among preschool children the symptoms of depression are evidenced by a lack of smiling, apathy towards play and a significant loss of involvement in any activity. These children may become easily irritable or tearful. Among school-aged children, deteriorating school performance and avoidance of peers may signal depression. Increased irritability, argumentativeness, a fighting mood or refusal to go to school may be associated features of depression in these children. They may engage in activities that may be destructive to themselves and others, and to property. Repetitive physical complaints, like a stomachache or headache, are not uncommon in this age group. Depressed adolescents, on the other hand, experience and harbour guilt, hopelessness and negative beliefs about their future. At a physical level, unlike adult depression, there is hardly any sleep or appetite disturbance in childhood depression. However, failure of children to gain weight (with age) should alert the clinician to evaluate for a chronic form of depression. Other symptoms that may call for evaluation of depression among children are: poor self esteem, poor concentration, withdrawal from social activities, social phobia, hypersomnia, negativistic or antisocial behaviour, alcohol or substance abuse and death wishes.
The presence of major depression in a child or adolescent also increases the risk of an additional psychiatric disorder ten-to-twenty-fold – like anxiety disorders, conduct disorders, attention-deficit/hyperactivity disorders and substance use disorders. Quite often these psychiatric conditions coexist with depression.
Depression in children and adolescents is treatable. Both Psychotherapy as well as Pharmacotherapy is known to be effective in treating children with depression. It is necessary to assess the family environment, because depressed preschoolers are at high risk of having been victims of some form of maltreatment. Family members must be educated about the illness, its outcome and the available treatment forms. They should know that the child might require long-term social skills training to prevent recurrences.
The use of antidepressant medication requires a thorough baseline physical examination; a base line ECG is also required.
Dr. Unnati Kumar: MD, Consultant Psychiatrist
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