Single episode, mild F32.0
Single episode, moderate F32.1
Recurrent, mild F33.0
Recurrent, moderate F33.1
Major depressive disorder (MDD) is part of a cluster of diagnoses called the depressive disorders. 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.
MDD is a psychiatric disorder that affects approximately 10% of youth. MDD is characterized by a two week period (at minimum) during which at least five of the following symptoms (one of which must be either depressed mood and/or loss of interest in previously enjoyable activities) are present:
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. Some youth may be naturally fidgety or have trouble concentrating, if these symptoms existed prior to the depressed mood, caution must be taken in attributing them to the depressive episode. Related, it is natural for a child or adolescent to experience symptoms of depression following a significant loss (e.g., death of a family member) and bereavement must be considered first when these symptoms present within the context of a loss. Finally, depressive symptoms may also occur within the context of a bipolar spectrum disorder, if a youth becomes depressed after first experiencing a period during which his/her mood was abnormally elevated and s/he had high energy, it is possible that s/he is experiencing an episode of bipolar depression.
The presentation of major depressive disorder varies across people. Some people will be very severely debilitated, while others may experience milder symptoms that are not evident to others. Youth are less likely to experience very severe MDD (prevalence ~2.5%), this may contribute to the illness going undiagnosed.
Because the symptoms are primarily internal (i.e., cognitive and somatic) others may be unaware when a child or adolescent is depressed; changes in functioning and activity, along with somatic complaints and irritability are important signs to pay attention to. Additionally, many youth with MDD will also experience anxiety, including generalized anxiety disorder, panic, or separation anxiety. In older youth, substance use is also very common among people who have depression. The prevalence of MDD increases sharply at puberty - especially among females. The rate of depression among females is about twice as high following puberty.
There are multiple risk factors for depression; 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 depression 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.
Major depression can be treated, and early treatment can help to prevent future episodes. The evidence-based treatment guidelines 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.
Other classes of antidepressant medications such as venlafaxine, mirtazapine, and bupropion have also been tested, but do not consistently show efficacy in RCTs.
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.
Other classes of antidepressant medications such as venlafaxine, mirtazapine, and bupropion have also been tested, but do not consistently show efficacy in RCTs.
Major Depressive Disorder (MDD) is a relatively common mood disorder that can affect how a young person thinks, feels, and behaves.
This video from Psych Hub explores the symptoms and frequency of MDD in children and adolescents, as well as the treatment options available.
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Psych Hub is an educational service. The information provided in this video is not a substitute for professional advice, diagnosis, or treatment. If you believe you or someone you know may be experiencing mental health symptoms, please seek help from a qualified medical or behavioral health professional.
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