Depressive disorders are a group of psychiatric conditions that include:
The depressive disorders are characterized primarily by mood disturbance (sad, empty, or irritable mood). Individuals with depressive disorders often experience significant somatic changes, such as disruptions in sleep (insomnia or hypersomnia), eating (overeating or loss of appetite), or energy level. Changes in cognition, such as difficulty concentrating, indecisiveness, and morbid ideation (such as thoughts of death) are also common.
Individuals with major depressive disorder experience pervasive sadness or anhedonia (loss of interest) along with significant changes in somatic and/or cognitive functioning. To be diagnosed, these problems must be present nearly every day for at least two weeks. Individuals with persistent depressive disorder (dysthymia) experience similar symptoms, including sad mood and problems with somatic and/or cognitive functioning that occur most days for at least two years. Disruptive mood dysregulation disorder is diagnosed in children under 12 years old who experience persistent irritability and extreme behavioral dyscontrol.
These disorders can go undetected in youth because they are internalizing disorders, whereas many other childhood disorders are associated with externalizing symptoms, which are more likely to draw attention from parents and teachers. The exception is disruptive mood dysregulation disorder, which is characterized by temper outbursts; this may be related to an inability to effectively express internal distress and is likely to result in misdiagnosis as oppositional defiant disorder or bipolar disorder.
Major depressive disorder (MDD) is an episodic illness; though some people experience only one episode, the majority will experience recurrent episodes. This may be particularly true for children; youth who become depressed often continue to struggle with depressed mood as adults. In contrast, both disruptive mood dysregulation disorder (DMDD) and persistent depressive disorder (PDD) are more chronic illnesses. Youth who meet criteria for DMDD or PDD must experience symptoms for at least one year with no more than two months (cumulative) symptom-free. Though DMDD and PDD can be longer lasting than an episode of major depression, the symptoms are usually not as severe. DMDD is characterized by persistent irritability and temper tantrums. PDD is more similar to major depression symptomatically - youth with this illness experience sad / depressed mood along with physical and cognitive symptoms.
All of the depressive disorders represent a change in functioning; though PDD and DMDD have a more chronic presentation, all three illnesses are episodic (although PDD and DMDD are defined by prolonged periods of low/irritable mood, these are also episodic; there must be a change of functioning at the onset of illness and the expectation is that symptoms will eventually remit) and, in most cases, there will be fluctuations in the severity of symptoms, due to time or treatment Many people with depressive disorders also experience significant somatic symptoms, and youth may complain of headaches or stomach aches, along with exhibiting low energy. Additionally, many youth with a depressive disorder diagnosis experience hopelessness and suicidal thoughts. The risk of suicide is a significant concern in this population and should be monitored closely.
PDD - also known as dysthymic disorder - is a psychiatric disorder that affects approximately 1.5% of children and between 1.5% and 8% of adolescents.
PDD is characterized by a year-long period (at minimum) of depressed or irritable mood during which at least two of the following symptoms are also present:
During the year-long (at minimum) period, no more than two months may have been spent symptom-free. In addition, these symptoms must cause impairment in function - with one's family, friends, or at school - and, as mentioned above, they must represent a change in functioning. It is possible that a child or adolescent would meet criteria for major depressive disorder, which has a duration criteria of two weeks, but later meet criteria for PDD if his/her symptoms persist for at least a year. In this case, the youth would be diagnosed with MDD and PDD - this is sometimes called "double depression." Some youth may have trouble concentrating due to other factors, if symptoms of inattention or poor concentration existed prior to the depressed mood, caution must be taken in attributing them to the depressive episode. Finally, depressive symptoms may also occur within the context of a bipolar spectrum disorder, if a youth experiences a long period of depressed mood after first experiencing a period during which his/her mood was abnormally elevated and s/he had high energy or if s/he experiences days of elevated mood during the depression, it is possible that s/he is experiencing other specified bipolar disorder or cyclothymic disorder.
The presentation of persistent depressive disorder varies across people. Depending on the number and the severity of the symptoms, some people will be very severely debilitated, while others may have limited awareness of the effects of their depressed mood.
Because PDD represents a relatively chronic mood state, some youth (and their parents) may believe that they have "always" been this way and perceive their problems as personality or temperament - this may reduce the likelihood of treatment seeking. Additionally, because the symptoms are primarily internal others, may be unaware when a child or adolescent is depressed; changes in functioning and activity, along with chronic irritability are important signs to pay attention to. Comorbid disorders are common among people with PDD, including anxiety and (mostly in older youth) substance use. Youth with PDD are also at increased risk for developing a personality disorder as they age.
There is no evidence currently for clear differences in the risk factors for PDD as compared to MDD; among youth, family history of depression or other mental illness is a significant factor, increasing risk by two-to-four times. Early onset mood disorders tend to have a stronger genetic component than mood disorders that onset late in adolescence. Additionally, temperament and personality factors are related to risk for depression, youth who exhibit high negative affect (neuroticism) and/or perfectionistic tendencies may be at higher risk. Life events can also contribute to an individual's risk for depression; both traumatic, one-time events and chronic stressful living conditions increase vulnerability. Research using functional neuroimaging suggests that youth with MDD (we are unaware of neuroimaging research on youth with PDD specifically) show abnormal activity in the default mode network during resting state, which may be related to rumination. Additionally, youth with depression often exhibit hyperactivity of the amygdala and abnormal connectivity between the anterior cingulate and the amygdala during negative face emotion processing tasks. Finally, youth who experience chronic medical problems are more likely to develop depression than their peers.
We are not aware of any RCTs specific to PDD in youth. However, youth with PDD are sometimes included in trials for "depressed youth" and because PDD and MDD share a similar profile, it is likely that treatments with good empirical support for treating MDD will also be effective for PDD.
The evidence-based treatment guidelines for depression from the American Academy of Child and Adolescent Psychiatry and the Society for Clinical Child and Adolescent Psychology suggest that psychotherapy, including the family if possible, is the best approach with which to start. For youth who are severely depressed and/or do not respond to a course of evidence-based psychotherapy, antidepressant therapy may be initiated. However, there is research suggesting that for some youth there are significant side effects associated with SSRI antidepressant medication (e.g., suicidal ideation) and that the benefits are often minimal, so antidepressant therapy must be approached with caution and under the guidance of a child psychiatrist.
First Line Treatments
Second Line Treatments
In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, although not a substitute for the empirically supported treatments described above, might be considered.
The evidence-based treatment guidelines for depression from the American Academy of Child and Adolescent Psychiatry and the Society for Clinical Child and Adolescent Psychology suggest that psychotherapy, including the family if possible, is the best approach with which to start. For youth who are severely depressed and/or do not respond to a course of evidence-based psychotherapy, antidepressant therapy may be initiated. However, there is research suggesting that for some youth there are significant side effects associated with SSRI antidepressant medication (e.g., suicidal ideation) and that the benefits are often minimal, so antidepressant therapy must be approached with caution and under the guidance of a child psychiatrist.
First Line Treatments
Second Line Treatments
In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, although not a substitute for the empirically supported treatments described above, might be considered.