Evidence-Based Reviews

Adolescent depression: Diagnostic skills can differentiate teen angst from psychopathology

Current Psychiatry. 2002 July;1(7):40-50

Depression in teenagers is persistent and characterized by high rates of comorbid psychiatric conditions. Based on clinical evidence, the following strategies can help you determine appropriate treatment.

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References

1. Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews JA. Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school. J Abnorm Psychol 1993;102:133-44.

2. Kessler RC, Avenevoli S, Merikangas KR. Mood disorders in children and adolescents: an epidemiological perspective. Biol Psychiatry 2001;49:1002-14.

3. Jaffee SR, Moffitt TE, Caspi A, et al. Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Arch Gen Psychiatry 2002;58:215-22.

4. Lewinsohn PM, Rohde P, Seeley JR, Klein DN, Gotlib IH. Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. Am J Psychiatry 2000;157:1884-1591.

5. Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grow up. JAMA 2000;281:1707-13.

6. Pfeffer CR. Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention. Biol Psychiatry 2001;49:1055-61.

7. Carlson GA. The challenge of diagnosing depression in childhood and adolescence. J Affect Dis 2000;61(suppl 1):3-8.

8. Emslie GJ, Rush AJ, Weiberg WA, et al. A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry 1997;54:1031-7.

9. Emslie GJ, Heligenstein JH, Wagner KD, et al. Fluoxetine for acute treatment of depression in children and adolescents (poster presentation). Honolulu, Hawaii: American Academy of Child and Adolescent Psychiatry annual meeting, October 23-28, 2001.

10. Wagner KD, Robb AS, Findling R, Tiseo PJ. Citalopram is effective in the treatment of major depressive disorder in children and adolescents: results of a placebo-controlled (poster presentation). Waikoloa, Hawaii: American College of Neuropsychopharmacology annual meeting, December 9-13, 2001.

11. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 1998;37:63S-83S.

12. Clarke GN, Rohde P, Lewinsohn PM, Hops H, Seeley JR. Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions. J Am Acad Child Adolesc Psychiatry 1999;38:272-9.

13. Harrington R, Whittaker J, Shoebridge P, Campbell F. Systematic review of efficacy of cognitive behavior therapies in childhood and adolescent depressive disorder. BMJ 1998;316:1559-63.

14. Keller MB, Ryan ND, Birmaher B, et al. Efficacy of paroxetine in the treatment of adolescent major depression: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2001;40:762-72.

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Adolescents with depressive disorders tend to arrive in psychiatrists’ offices when their behavior has already been identified as problematic. Suicide attempts, academic failure, substance abuse, and family conflicts can all lead to teen psychiatric referrals. Other times, subtler changes in behavior may lead a family doctor or pediatrician to suspect depression and to send an adolescent to you for a psychiatric consultation.

The psychiatrist’s task is challenging. Adolescents are usually brought in by their worried parents and may not want to talk to a psychiatrist. Or they may be unable to accurately describe their internal states. Even people who know an adolescent well may not discern the emotions that drive his or her behavior. Adding to the mix are the recurrent nature of major depression in adolescents and the likelihood of complicating comorbid psychiatric conditions (Box).^1-6

Based on clinical evidence, we offer advice to help you promptly identify and effectively treat adolescents with depressive disorders. We also provide preliminary information on two studies examining medication treatment, psychotherapy, and combined treatment for teens with major depression.

Adolescent depression disorders

Symptoms of depression in adolescents are similar to those in adults, and it is appropriate for psychiatrists to use DSM-IV diagnostic criteria for making the diagnosis. The three primary depressive disorders for both adults and adolescents are major depressive disorder (MDD), dysthymic disorder, and depressive disorder not otherwise specified (NOS).

Box

ADOLESCENT DEPRESSION: PORTRAIT OF A PERSISTENT DISORDER

Depression is relatively rare among children but becomes common after the onset of puberty. In particular, recurrent depression often starts in adolescence. Here are the statistics:

Up to 9% of adolescents meet diagnostic criteria for major depressive disorder (MDD), and up to 25% suffer from it by their late teens.
MDD affects boys and girls equally in childhood, but the prevalence seems to increase in girls after puberty.^1,2
Depression in adolescents is characterized by high rates of comorbid psychiatric conditions. In general, the younger the age of onset, the higher the rate of comorbid conduct disorder, attention-deficit/hyperactivity disorder, and/or anxiety disorder.³
Adolescent depression tends to persist. An estimated 45 to 70% of children and adolescents with MDD have recurrent episodes.⁴ At particularly high risk for recurrence are adolescent girls with depression, adolescents with multiple MDD episodes, and adolescents with a family history of recurrent depression.
As many as 50% of teens with MDD attempt suicide within 15 years of their initial episode, and more than 20% make recurrent attempts.^4,5 No good estimates of the rate of completed suicide are available. One 15-year follow-up of a sample of depressed adolescents reported a suicide rate of 7.7%.⁵ Boys are much more likely to complete suicide than girls across all racial groups.⁶

Although the symptoms that make up the diagnostic criteria are similar for adults and teens, the behavioral manifestations and response to treatment may differ. The adolescent may present as irritable and angry, rather than overly sad. Impairments in functioning are likely to be related to decline in school performance, social withdrawal, or increased conflicts with peers and family.

As for treatment, certain antidepressant medications of proven efficacy in adults (i.e., tricyclics) do not seem to work for adolescents.

MDD is a time-limited episode of depressive symptoms severe enough to cause functional impairment, such as decline in school performance, social withdrawal, or increased conflicts with peers and family. Symptoms must be present at least 2 weeks.

Dysthymia is a chronic depression that is less severe than MDD and lasts 1 year or longer without sustained remission. It often begins early in childhood and may include periods of increased symptoms consistent with major depression (sometimes called “double depression”).

Depressive disorder NOS is a category of depression that, though clinically significant, does not meet the full criteria for severity, duration, or level of impairment of MDD or dysthymia.

Unless otherwise specified, the terms “depression” and “depressive disorder” in this article are used generically to include all three of these disorders.

Depressive disorders must be differentiated from bipolar disorder, which is characterized by least one prior episode of mania (for bipolar type I) or hypomania (for bipolar type II). The clinical picture of bipolar disorder in youths may differ from that seen in adults. For example, bipolar youth often present with dysphoric mood interspersed with frequent, short periods of intense emotional lability and irritability, rather than “classic” euphoria.

Diagnosis

To diagnose a depressive disorder in an adolescent, information is typically obtained from multiple sources, most commonly the teenage patient and at least one of the parents. Because several sources are involved, however, the information may be conflicting. For instance, the adolescent may contradict a parent’s report that he or she is having difficulties in school or has a substance abuse problem.