Major Depressive Disorder in Children and Adolescents

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.

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

• Cognitive-behavioral therapy consists of challenging negative cognitions and increasing activity in order to counteract the destructive through patterns and withdrawal that are common among people with depression.

• Interpersonal therapy is based on the idea that relationships with other people can cause or prevent symptoms of depression. Treatment consists of identifying problem relationships, improving communication skills, using new skills to improve significant relationships.

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• SSRI antidepressant medications, which are thought to help by improving the amount of serotonin in the brain. The only medication with FDA approval for treating adolescent depression is fluoxetine. Other SSRIs are also used, but in trials, fluoxetine show a stronger effect, relative to placebo, possibly due to its longer half life.

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.

• Dialectical behavior therapy
• Mindfulness-based cognitive therapy
• Exercise
• Supportive psychotherapy

Other classes of antidepressant medications such as venlafaxine, mirtazapine, and bupropion have also been tested, but do not consistently show efficacy in RCTs.