Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis

Liza Bonin, PhD
Section Editors
David Brent, MD
Diane Blake, MD
Deputy Editor
David Solomon, MD


Depressive disorders are common in children and adolescents [1,2], impair psychosocial functioning, and are often accompanied by comorbid psychopathology [3,4]. Despite its detrimental effects, pediatric depression is often undertreated.

The epidemiology, clinical manifestations, assessment, and diagnosis of pediatric depression are reviewed here. Treatment of depression in youths is discussed separately. (See "Overview of treatment for pediatric depression" and "Pediatric unipolar depression and pharmacotherapy: General principles" and "Pediatric unipolar depression and pharmacotherapy: Choosing a medication" and "Pediatric unipolar depression: Psychotherapy".)


Prevalence — The risk for depression increases during childhood [5]. As an example, a survey of more than 78,000 parents in the United States in 2007 found that among their children, the point prevalence of depression for different age groups was as follows [2]:

3 to 5 years – 0.5 percent

6 to 11 years – 1.4 percent


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 16, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. 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.
  2. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health surveillance among children--United States, 2005-2011. MMWR Suppl 2013; 62:1.
  3. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007; 120:e1299.
  4. Asarnow JR, Jaycox LH, Duan N, et al. Depression and role impairment among adolescents in primary care clinics. J Adolesc Health 2005; 37:477.
  5. Wesselhoeft R, Sørensen MJ, Heiervang ER, Bilenberg N. Subthreshold depression in children and adolescents - a systematic review. J Affect Disord 2013; 151:7.
  6. Avenevoli S, Swendsen J, He JP, et al. Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry 2015; 54:37.
  7. Seedat S, Scott KM, Angermeyer MC, et al. Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry 2009; 66:785.
  8. Maughan B, Collishaw S, Stringaris A. Depression in childhood and adolescence. J Can Acad Child Adolesc Psychiatry 2013; 22:35.
  9. Douglas J, Scott J. A systematic review of gender-specific rates of unipolar and bipolar disorders in community studies of pre-pubertal children. Bipolar Disord 2014; 16:5.
  10. Fleming JE, Offord DR. Epidemiology of childhood depressive disorders: a critical review. J Am Acad Child Adolesc Psychiatry 1990; 29:571.
  11. Kutcher S, Marton P. Affective disorders in first-degree relatives of adolescent onset bipolars, unipolars, and normal controls. J Am Acad Child Adolesc Psychiatry 1991; 30:75.
  12. Warner V, Weissman MM, Mufson L, Wickramaratne PJ. Grandparents, parents, and grandchildren at high risk for depression: a three-generation study. J Am Acad Child Adolesc Psychiatry 1999; 38:289.
  13. Lewinsohn PM, Roberts RE, Seeley JR, et al. Adolescent psychopathology: II. Psychosocial risk factors for depression. J Abnorm Psychol 1994; 103:302.
  14. Rutter, M. Children of sick parents: An environment and psychiatric study, Oxford University Press, London 1966.
  15. Reinherz HZ, Giaconia RM, Pakiz B, et al. Psychosocial risks for major depression in late adolescence: a longitudinal community study. J Am Acad Child Adolesc Psychiatry 1993; 32:1155.
  16. Adrian C, Hammen C. Stress exposure and stress generation in children of depressed mothers. J Consult Clin Psychol 1993; 61:354.
  17. Garber, J, Hilsman, R. Cognition, stress and depression in children and adolescents. Child Adolesc Psychiatr Clin N Am 1992; 1:129.
  18. Hilsman R, Garber J. A test of the cognitive diathesis-stress model of depression in children: academic stressors, attributional style, perceived competence, and control. J Pers Soc Psychol 1995; 69:370.
  19. Burke P, Elliott M. Depression in pediatric chronic illness. A diathesis-stress model. Psychosomatics 1999; 40:5.
  20. Kendler KS. Genetic epidemiology in psychiatry. Taking both genes and environment seriously. Arch Gen Psychiatry 1995; 52:895.
  21. Williamson DE, Birmaher B, Frank E, et al. Nature of life events and difficulties in depressed adolescents. J Am Acad Child Adolesc Psychiatry 1998; 37:1049.
  22. Stringaris A, Lewis G, Maughan B. Developmental pathways from childhood conduct problems to early adult depression: findings from the ALSPAC cohort. Br J Psychiatry 2014; 205:17.
  23. Tsai MC, Tsai KJ, Wang HK, et al. Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study. J Pediatr 2014; 164:136.
  24. Chrisman SP, Richardson LP. Prevalence of diagnosed depression in adolescents with history of concussion. J Adolesc Health 2014; 54:582.
  25. Luby JL, Gaffrey MS, Tillman R, et al. Trajectories of preschool disorders to full DSM depression at school age and early adolescence: continuity of preschool depression. Am J Psychiatry 2014; 171:768.
  26. Pearson RM, Evans J, Kounali D, et al. Maternal depression during pregnancy and the postnatal period: risks and possible mechanisms for offspring depression at age 18 years. JAMA Psychiatry 2013; 70:1312.
  27. Bowes L, Joinson C, Wolke D, Lewis G. Peer victimisation during adolescence and its impact on depression in early adulthood: prospective cohort study in the United Kingdom. BMJ 2015; 350:h2469.
  28. Hamm MP, Newton AS, Chisholm A, et al. Prevalence and Effect of Cyberbullying on Children and Young People: A Scoping Review of Social Media Studies. JAMA Pediatr 2015; 169:770.
  29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  30. Cicchetti D, Toth SL. The development of depression in children and adolescents. Am Psychol 1998; 53:221.
  31. Stringaris A, Maughan B, Copeland WS, et al. Irritable mood as a symptom of depression in youth: prevalence, developmental, and clinical correlates in the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry 2013; 52:831.
  32. Stringaris A, Cohen P, Pine DS, Leibenluft E. Adult outcomes of youth irritability: a 20-year prospective community-based study. Am J Psychiatry 2009; 166:1048.
  33. Lehrer JA, Shrier LA, Gortmaker S, Buka S. Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students. Pediatrics 2006; 118:189.
  34. Hankin BL. Future directions in vulnerability to depression among youth: integrating risk factors and processes across multiple levels of analysis. J Clin Child Adolesc Psychol 2012; 41:695.
  35. Deykin EY, Buka SL, Zeena TH. Depressive illness among chemically dependent adolescents. Am J Psychiatry 1992; 149:1341.
  36. Brown RA, Lewinsohn PM, Seeley JR, Wagner EF. Cigarette smoking, major depression, and other psychiatric disorders among adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35:1602.
  37. Joiner, T, Coyne, JC. The Interactional Nature of Depression, American Psychological Association, Washington DC 1999.
  38. Beasley PJ, Beardslee WR. Depression in the adolescent patient. Adolesc Med 1998; 9:351.
  39. Lewinsohn PM, Rohde P, Seeley JR, et al. Psychosocial functioning of young adults who have experienced and recovered from major depressive disorder during adolescence. J Abnorm Psychol 2003; 112:353.
  40. Giaconia RM, Reinherz HZ, Paradis AD, et al. Major depression and drug disorders in adolescence: general and specific impairments in early adulthood. J Am Acad Child Adolesc Psychiatry 2001; 40:1426.
  41. Naicker K, Galambos NL, Zeng Y, et al. Social, demographic, and health outcomes in the 10 years following adolescent depression. J Adolesc Health 2013; 52:533.
  42. Birmaher B, Brent D, AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007; 46:1503.
  43. Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches. J Am Acad Child Adolesc Psychiatry 1999; 38:852.
  44. Bernstein GA, Massie ED, Thuras PD, et al. Somatic symptoms in anxious-depressed school refusers. J Am Acad Child Adolesc Psychiatry 1997; 36:661.
  45. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996; 35:1427.
  46. Goodyer IM, Herbert J, Secher SM, Pearson J. Short-term outcome of major depression: I. Comorbidity and severity at presentation as predictors of persistent disorder. J Am Acad Child Adolesc Psychiatry 1997; 36:179.
  47. Lewinsohn PM, Rohde P, Seeley JR. Adolescent psychopathology: III. The clinical consequences of comorbidity. J Am Acad Child Adolesc Psychiatry 1995; 34:510.
  48. Fombonne E, Wostear G, Cooper V, et al. The Maudsley long-term follow-up of child and adolescent depression. 1. Psychiatric outcomes in adulthood. Br J Psychiatry 2001; 179:210.
  49. Fombonne E, Wostear G, Cooper V, et al. The Maudsley long-term follow-up of child and adolescent depression. 2. Suicidality, criminality and social dysfunction in adulthood. Br J Psychiatry 2001; 179:218.
  50. Axelson D, Goldstein B, Goldstein T, et al. Diagnostic Precursors to Bipolar Disorder in Offspring of Parents With Bipolar Disorder: A Longitudinal Study. Am J Psychiatry 2015; 172:638.
  51. Faedda GL, Serra G, Marangoni C, et al. Clinical risk factors for bipolar disorders: a systematic review of prospective studies. J Affect Disord 2014; 168:314.
  52. Goldstein BI, Carnethon MR, Matthews KA, et al. Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2015; 132:965.
  53. Birmaher B, Arbelaez C, Brent D. Course and outcome of child and adolescent major depressive disorder. Child Adolesc Psychiatr Clin N Am 2002; 11:619.
  54. Birmaher, B, Brent, D. Depressive disorders. In: Pediatric Psychopharmacology: Principles and Practice, Martin, Scahill, et al, (Eds). Oxford University Press, Oxford 2003. p.466.
  55. Work Group on Psychiatric Evaluation, American Psychiatric Association Steering Committee on Practice Guidlines. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry 2006; 163:3.
  56. American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults, Second Edition, 2006. http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on July 18, 2011).
  57. Freudenreich O, Nejad SH, Francis A, Fricchione GL. Psychosis, mania, and catatonia. In: Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL. (Ed), American Psychiatric Publishing, Washington, DC 2011. p.219.
  58. Brent DA, Birmaher B. Clinical practice. Adolescent depression. N Engl J Med 2002; 347:667.
  59. Thapar A, McGuffin P. Validity of the shortened Mood and Feelings Questionnaire in a community sample of children and adolescents: a preliminary research note. Psychiatry Res 1998; 81:259.
  60. Wood A, Kroll L, Moore A, Harrington R. Properties of the mood and feelings questionnaire in adolescent psychiatric outpatients: a research note. J Child Psychol Psychiatry 1995; 36:327.
  61. Olino TM, Yu L, McMakin DL, et al. Comparisons across depression assessment instruments in adolescence and young adulthood: an item response theory study using two linking methods. J Abnorm Child Psychol 2013; 41:1267.
  62. BECK AT, WARD CH, MENDELSON M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561.
  63. Kovacs M. Rating scales to assess depression in school-aged children. Acta Paedopsychiatr 1981; 46:305.
  64. Reynolds, WM. Adolescent Depression Scale, Psychological Assessment Resources, Inc, Odessa, FL 1987.
  65. Ayuso-Mateos JL, Nuevo R, Verdes E, et al. From depressive symptoms to depressive disorders: the relevance of thresholds. Br J Psychiatry 2010; 196:365.
  66. Lewinsohn PM, Klein DN, Durbin EC, et al. Family study of subthreshold depressive symptoms: risk factor for MDD? J Affect Disord 2003; 77:149.
  67. Bowden CL. A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord 2005; 84:117.
  68. Frye MA, Calabrese JR, Reed ML, et al. Use of health care services among persons who screen positive for bipolar disorder. Psychiatr Serv 2005; 56:1529.
  69. Smith DJ, Griffiths E, Kelly M, et al. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry 2011; 199:49.
  70. Stensland MD, Schultz JF, Frytak JR. Diagnosis of unipolar depression following initial identification of bipolar disorder: a common and costly misdiagnosis. J Clin Psychiatry 2008; 69:749.
  71. Hu C, Xiang YT, Ungvari GS, et al. Undiagnosed bipolar disorder in patients treated for major depression in China. J Affect Disord 2012; 140:181.
  72. Hantouche EG, Akiskal HS, Lancrenon S, et al. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord 1998; 50:163.
  73. Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry 1995; 34:454.
  74. Kupfer DJ, Frank E, Grochocinski VJ, et al. Demographic and clinical characteristics of individuals in a bipolar disorder case registry. J Clin Psychiatry 2002; 63:120.
  75. Cha B, Kim JH, Ha TH, et al. Polarity of the first episode and time to diagnosis of bipolar I disorder. Psychiatry Investig 2009; 6:96.
  76. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002; 159:1.
  77. Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002; 59:530.
  78. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003; 60:261.
  79. Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med 2005; 67:1.
  80. Matza LS, Rajagopalan KS, Thompson CL, de Lissovoy G. Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs. J Clin Psychiatry 2005; 66:1432.