Patient information: Depression in adolescents (Beyond the Basics)
- Liza Bonin, PhD
Liza Bonin, PhD
- Associate Professor of Pediatrics and Psychiatry
- Baylor College of Medicine
Depression is a medical condition that can cause a wide variety of psychological and physical symptoms. It is estimated that between 4 and 8 percent of adolescents are depressed. However, depression in adolescents is probably underdiagnosed because the symptoms can be difficult to recognize.
Extreme and enduring sadness is the best-known symptom of depression, although adolescents can have a number of other symptoms, including irritability, difficulty at school, changes in sleep habits, and/or feelings of worthlessness. Depression is different than occasional blues and grief because depression is persistent and often interferes with the teen's ability to get along with parents and friends, complete school work, and appropriately participate in other normal daily activities.
Depression is a treatable condition. Psychotherapy (counseling), drug therapy, and other measures can alleviate symptoms and help the adolescent to succeed in school, develop and maintain healthy relationships, and feel more self-confident. This topic review discusses the causes, risk factors, signs and symptoms, and diagnosis of depression in adolescents. A separate topic review discusses the treatment of depression in adolescents. (See "Patient information: Depression treatment options for adolescents (Beyond the Basics)".)
Topics that discuss depression in adults are also available. (See "Patient information: Depression in adults (Beyond the Basics)" and "Patient information: Depression treatment options for adults (Beyond the Basics)".)
CAUSE OF DEPRESSION
The exact cause of depression is not known. Studies suggest that depression is a biologic disorder resulting, at least in part, from an imbalance of neurochemicals in the brain, including serotonin, norepinephrine, and dopamine. These neurochemicals allow cells in the brain to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions. This interaction is supported by studies demonstrating the benefit of antidepressants, which help restore the neurochemical balance in the brain.
DEPRESSION RISK FACTORS
Many adolescents are unsure why they are depressed. Depression sometimes occurs in response to a stressful event, such as a recent death or break-up, or it can occur for no apparent reason. Although anyone can develop depression, certain factors increase an adolescent's risk for becoming depressed, including:
●A history of depression in a parent or sibling
●A prior history of depression
●A history of anxiety disorder, attention deficit hyperactivity disorder, learning disability
●A recent loss (eg, death, divorce)
●Family problems or conflicts with parents
●Difficulties with friends or peers
●Difficulties with school work
●Negative outlook or poor coping skills
IMPACT OF DEPRESSION
Many adolescents who are depressed are not aware that depression is the basis for the changes in their emotions, ability to interact with others, and school performance. These changes can have serious, life-altering consequences that increase the risk for future depressive episodes, especially if the depression is not recognized or treated. Adolescents who are depressed are at increased risk for the following problems:
●Difficulty with school work and relationships with parents and peers, decreased interest and involvement in daily activities and responsibilities.
●Health complaints such as abdominal pain, fatigue, and headaches.
●Engaging in high-risk behaviors such as having sex, smoking, abusing alcohol and other substances, violence against others, and suicide attempts.
Preventing suicide — Suicide is a tragic and preventable consequence of severe depression. Any mention of suicide or self-harm should be taken seriously. Signs that a teen is considering suicide include the following :
●Ideation — Talking about or threatening to kill or hurt oneself; looking for ways to kill oneself; talking or writing about death, dying or suicide
●Substance abuse — Increased substance use
●Anxiety — Anxiety, agitation, or changes in sleep pattern
●Trapped — Feeling like there is no way out
●Withdrawal — Withdrawing from friends, family, and society
Parents who are concerned that their child is considering suicide should seek care as soon as possible. If the parent is concerned that the child is at risk of hurting him or herself or others, the parent should do one of the following:
●Call their healthcare provider for advice or an urgent appointment
●Take the child to the local emergency department
●Call the National Suicide Prevention Lifeline (www.suicidepreventionlifeline.org) at 1-800-273-TALK (8255).
An adolescent who is at immediate risk for attempting suicide requires emergency evaluation and prompt treatment for depression (if depression precipitated the suicidal thoughts). This may include hospitalization, antidepressant medication, and intensive therapy.
It is sometimes difficult to differentiate the signs and symptoms of depression from the occasional bad mood, acting out, and negative attitude that most adolescents experience at some point. It is not uncommon for the transition from childhood to adulthood to include conflict and anger as the teen tries to adjust to their changing body and role among family and friends. The primary difference between "normal" adolescent behavior disruptions and depression is that depression leads to a significant change in mood that lasts for at least two weeks and includes some associated symptoms (see below). If a parent is unsure whether their teen is depressed, they should err on the side caution and ask the child's healthcare professional for advice.
A depressed or irritable mood may be the most common symptom of depression, although depression can cause other psychological and physical symptoms. Unfortunately, there is no single sign or symptom that serves as a marker for depression, which can make depression hard to identify. In fact, many people are not aware that depression can cause physical symptoms such as aches and pains or appetite and sleep changes.
A typical major depressive episode lasts an average of seven to nine months; 90 percent of adolescents with depression improve within two years. Unfortunately, relapse is common; the probability of recurrence is 40 percent by two years and 70 percent by five years.
The three distinct types of depression (major depression, dysthymia, and depressive disorder not otherwise specified) will be discussed here.
Major depression — Major depression is the medical term for depression that includes at least five of the symptoms listed below. A person can have mild, moderate, or severe major depression.
●Depressed or irritable mood for most of the day nearly every day
●Markedly diminished interest or pleasure in almost all activities
●Change in appetite or weight
●Insomnia or excessive sleep
●Talking or moving more slowly or quickly than normal
●Fatigue or loss of energy
●Feelings of worthlessness or guilt
●Difficulty concentrating or making decisions
●Recurring thoughts of death or suicide
One of first two symptoms must be present to diagnose depression: the adolescent must have either a depressed/irritable mood or loss of interest or pleasure for most of the day, nearly every day, for at least two weeks. In addition, four or more of the other symptoms must also be present during the same period.
Other potential causes of depressive symptoms (eg, drug abuse or medications), medical conditions (eg, hypothyroidism), and grief (eg, due to death of friend or family member) must be excluded as causes (see 'Related conditions' below).
Depressed mood — The definition of a "depressed mood" in adolescents is somewhat different than depressed mood in an adult. Many adolescents describe feeling down, sad, or blue much of the time. In adolescents, irritability may be a better indicator of depression.
Signs of irritability include feeling "annoyed" or "bothered" by everything and everyone. Rather than expressing sadness, the depressed adolescent may be moody, negative, and argumentative, picking fights as a means to express his or her emotional distress. He or she often is unable to tolerate frustration and responds to minor provocations with angry outbursts.
Other characteristics of depressed mood in adolescents include:
●Finding others uncaring
●Brooding about real or potentially unpleasant circumstances
●A gloomy or hopeless outlook
●Belief that everything is "unfair"
●Feelings that they disappoint parents or teachers
Diminished interest or pleasure — Adolescents experience diminished interest by feeling that events, hobbies, interests, or people are less interesting or fun than they used to be. They may use terms like "boring," "stupid," or "uninteresting." They may withdraw from or lose interest in friends. If they are sexually active, they may have decreased libido or interest in sex.
Change in appetite or weight — Appetite changes and weight loss are common in people with depression, although this may be less common in depressed adolescents than in depressed adults.
Changes in sleep — Sleep disturbance is common in depressed adolescents; complaints may include not feeling rested after sleeping or having difficulty getting out of bed in the morning. A depressed adolescent may have difficulty falling or staying asleep, may sleep excessively during the day or night, or may sleep at odd hours.
Slowed or rapid movement — Talking or moving more slowly or quickly than normal is common in depressed youth; the medical term for this is psychomotor retardation or agitation. Adolescents can have alternating periods of retardation and agitation within a single episode of depression.
●Psychomotor retardation (slowing) is defined an abnormal slowing of movement. It is directly related to brain activity and causes the person to appears as if he or she is moving in slow motion; the feeling of being slowed down is not psychomotor retardation.
●Psychomotor agitation may cause trouble sitting still, pacing, hand wringing, pulling at or rubbing clothes, tantrums, yelling, shouting, or non-stop talking.
Fatigue or loss of energy — A depressed adolescent may report feeling tired all the time, exhausted, listless, and without energy or motivation. He or she may feel the need to rest during the day, experience heaviness in their arms or legs, or feel like it is hard to get going much of the time. Parents can sometimes misinterpret this behavior as laziness, a bad attitude, or a desire to avoid responsibilities. Alternatively, some parents are concerned that the adolescent is medically ill.
Feelings of worthlessness or guilt — Many depressed adolescents have feelings of inadequacy, inferiority, failure, or worthlessness. One or more of the following may be present:
●Reluctance to try to do things (fear of failure)
●Excessively self-critical assessment of accomplishments
●Difficulty identifying positive self attributes
●Desire to change several aspects of themselves
●An "I don't care" attitude to avoid feelings of insecurity
●Compulsive lying about success or skills to bolster self-esteem
●Envy or preoccupation with the success of others
●Marked self-reproach or guilt for events that are not their fault
●Belief that they deserve to be punished for things that are not their fault
Impaired concentration, indecisiveness — Depressed adolescents usually have problems with attention and concentration that were not present to the same degree before the episode of depression. Their thinking and processing of information may be slowed. In addition, they are indecisive, which may cause procrastination, helplessness, or inability to take action. They take longer to complete homework and class work than before the depressive episode; school performance may decline. It may be necessary to obtain information from the school to determine if this problem is present.
Recurring thoughts of death or suicide — Some depressed adolescents experience recurrent thoughts of death (not just fear of death) or suicide or even attempt suicide. Morbid thoughts are common in depressed teens and manifest as:
●Thoughts that life is not worth living
●Thoughts that others would be better off if they were dead
●Preoccupation with music and literature that has morbid themes
Dysthymia — Dysthymia is a less intense but more persistent condition than major depression. Dysthymia is usually diagnosed when a person has a depressed or irritable mood for at least one year and has at least two other symptoms of depression. The most common symptoms of dysthymia include changes in appetite and/or sleep, fatigue, low self-esteem, difficulty concentrating and making decisions, and feelings of hopelessness.
Other types of depression — A teen can have some, but not all, of the features of major depression or dysthymia. Depression, independent of the type, results in problems with daily functioning and development. It is important that depression be addressed to prevent a worsening of symptoms and problems in daily life. Although other types of depression may have fewer or less severe symptoms, the adolescent should still be evaluated by a healthcare provider.
The diagnosis of depression is based upon a person's symptoms, the duration of their symptoms, and the overall effect of these symptoms on the person's life. Information from parents and teachers is often considered during the evaluation. The evaluation usually begins with the child's primary care provider (eg, pediatrician, family practitioner), although the ideal treatment for depressed adolescents should include referral to a trained mental health provider (eg, child psychiatrist, psychologist, or other specialist).
There is currently no medical test that identifies depression, although blood tests are often done to rule out other medical conditions that could be causing depression.
Related conditions — There are a few conditions that cause features similar to those of depression, including mood disorders related to a medical condition, substance abuse (eg, alcohol), or a loss. Other conditions that can cause symptoms of depression include bipolar disorder and adjustment disorder. As the healthcare provider evaluates the child's signs and symptoms of depression, he or she will determine if one of these other conditions could be the cause.
Mood disorder related to a medical condition — Several medical disorders can cause symptoms of depression, including hypothyroidism, adrenal insufficiency, post concussive syndrome, vitamin B12 deficiency, lupus, and mononucleosis. (See "Patient information: Hypothyroidism (underactive thyroid) (Beyond the Basics)" and "Patient information: Adrenal insufficiency (Addison's disease) (Beyond the Basics)" and "Patient information: Systemic lupus erythematosus (SLE) (Beyond the Basics)".)
Substance-related mood disorders — Drugs of abuse (eg, alcohol, cocaine, heroin, amphetamines) and prescription medications (eg, corticosteroids, epilepsy treatments, attention-deficit hyperactivity disorder treatments, birth control pills) can cause symptoms of depression in some adolescents.
Grief — Grief, also known as bereavement, is a normal reaction to many situations, including the loss of a loved one. It is often difficult to know if an adolescent who is grieving also suffers from depression. Adolescents who have feelings of hopelessness, helplessness, worthlessness, or guilt may be depressed, especially if these symptoms persist for several months beyond the loss.
Adjustment disorder with depressed mood — An adjustment disorder is a significant emotional or behavioral reaction to an identifiable stressor (eg, parental divorce, academic failure, or peer problems). Adjustment disorder with depressed mood (ADDM) is a likely diagnosis if the adolescent's symptoms are significant, develop within three months of the onset of the stressor(s), and resolve within six months after the stressor or its consequences. ADDM can persist beyond six months if the stressor continues (eg, ongoing parental conflict).
Bipolar disorder — Adolescents with bipolar disorder (manic depression) have periods of mania (feeling excessively elated, impulsive, irritable, or irrational) or hypomania (a milder form of mania), sometimes with periods of major depression. (See "Patient information: Bipolar disorder (manic depression) (Beyond the Basics)".)
Dealing with the diagnosis — Being diagnosed with depression is reassuring for some adolescents and their families; the diagnosis provides an explanation for symptoms such as fatigue, difficulty sleeping, and changes in appetite. Some families worry that they contributed to their adolescent's depression as a result of a divorce, move, or other life event. Still other families have difficulty recognizing that the adolescent's symptoms are those of depression, and continue to hope that the symptoms will simply go away without treatment.
These emotions can be difficult to sort out, and it is often helpful for the parent(s) as well as the adolescent to meet with a therapist or counselor, either together or separately.
WHEN TO SEEK HELP FOR DEPRESSION
Parents who are not sure if their adolescent is suffering from depression or just experiencing normal adolescent issues can consider the following questions:
●Does the teen's behavior differ from his or her normal behavior?
●Are the changes significant or severe?
●How long have the symptoms been present?
●Is the teen "annoyed" or "bothered" by everything and everyone?
●Is the teen moody, negative, or argumentative?
●Does the teen respond to minor provocations with angry outbursts?
●Does the teen have a hopeless outlook? Believe that everything is unfair?
●Has the teen withdrawn from or lost friends?
●Have relationships within the family been affected by the teen's mood?
●Have the teen's grades or schoolwork declined recently?
If a parent has any concerns that their adolescent could be depressed, he or she should contact the teen's healthcare provider as soon as possible to arrange an appointment. (See 'Preventing suicide' above.)
A separate topic review discusses treatment options for adolescents with depression. (See "Patient information: Depression treatment options for adolescents (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your adolescent's healthcare provider is the best source of information for questions and concerns related to your adolescent's medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient information: Depression (The Basics)
Patient information: Medicines for depression (The Basics)
Patient information: Electroconvulsive therapy (ECT) (The Basics)
Patient information: Anorexia nervosa (The Basics)
Patient information: Bulimia nervosa (The Basics)
Patient information: Post-traumatic stress disorder (The Basics)
Patient information: Antisocial personality disorder (The Basics)
Patient information: When you have depression and another health problem (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient information: Depression treatment options for adolescents (Beyond the Basics)
Patient information: Depression in adults (Beyond the Basics)
Patient information: Depression treatment options for adults (Beyond the Basics)
Patient information: Hypothyroidism (underactive thyroid) (Beyond the Basics)
Patient information: Adrenal insufficiency (Addison's disease) (Beyond the Basics)
Patient information: Systemic lupus erythematosus (SLE) (Beyond the Basics)
Patient information: Bipolar disorder (manic depression) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Unipolar depression in children and adolescents: Epidemiology, clinical features, assessment, and diagnosis
Effect of antidepressants on suicide risk in children and adolescents
Suicidal behavior in children and adolescents: Epidemiology and risk factors
Evaluation and management of suicidal behavior in children and adolescents
Overview of treatment for pediatric depression
Pediatric unipolar depression and pharmacotherapy: Choosing a medication
Psychosocial treatment for adolescent depression
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Mental Health
●The Nemours Foundation
●American Academy of Child and Adolescent Psychiatry
●Mental Health America
●American Foundation for Suicide Prevention
- Rudd MD, Berman AL, Joiner TE Jr, et al. Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav 2006; 36:255.
- Saluja G, Iachan R, Scheidt PC, et al. Prevalence of and risk factors for depressive symptoms among young adolescents. Arch Pediatr Adolesc Med 2004; 158:760.
- Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. J Am Acad Child Adolesc Psychiatry 1999; 38:56.
- Brent DA, Birmaher B. Clinical practice. Adolescent depression. N Engl J Med 2002; 347:667.
- Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. AACAP. J Am Acad Child Adolesc Psychiatry 1998; 37:63S.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.