When does sadness become depression?
It is normal to have 'good days' and 'bad days', providing there is a healthy balance.
When feelings of sadness, anxiety, anger and/or irritation are very strong, continue for a long time or occur very frequently, and start to interfere with enjoyment, goals and life at home, school or work, or with relationships and social interactions, it can become a depressive illness.
Many people with depression do not feel sad, instead they feel angry, irritated, anxious or absolutely nothing at all (indifferent/'blank').
DEPRESSION / DEPRESSIVE DISORDER
What are some signs of depression?
Frequent or chronic (constant) feelings of anxiety, irritability, sadness, anger or feeling 'nothing' Anhedonia (not enjoying previous interests), nihilism (hopelessness), guilty, shame or feelings of worthlessness or general negativity relating to self, one's life and others
Defiant, destructive, aggressive, careless or risky behaviour
Withdrawing from peers and family, as well as from activities, interests and social gatherings
Deteriorating school work, appearance, self-care and general social and emotional functioning
Difficulties with energy levels, concentration, sleep, appetite or unexplained physical symptoms
Thoughts of wanting to harm oneself or end one's life or hurt another person or persons
Hurting or harming (or trying to hurt) oneself in any way or harming (or trying to harm) others
Important numbers
Research provides the following numbers (numbers vary depending on context):
Depression likely affects at least 3% of adolescents and 0.5% of children under 12 years old.
The cumulative probability for depression in late adolescence may be as high as 20%.
Only more or less 50% of children and young people ask for help from parents or adults.
Only more or less 25% of children and young people with depression are detected and treated.
Children and young people with depression often present different to adults (e.g. somatic symptoms, anxiety or aggression), which means mental health problems such as Depression is often not identified or children are misdiagnosed (for instance with Conduct Disorder or ADHD).
Lifetime prevalence is said to be more or less 25%, which means one in four people are likely to present with depression during their lives. We know that more or less 50% of adults with depression do not seek help and are not diagnosed, which means the numbers might be higher.
What causes depression?
Anyone can become depressed and be diagnosed with a Depressive Illness. As with all mental health diagnoses, it is often helpful to think in terms of predisposing, precipitating, maintaining and protecting factors.
Some people are more vulnerable to develop depression than others. Genetic, psychological and social factors are relevant. People can be more vulnerable to depression when they are under high levels of chronic stress, especially when they have an anxious temperament or personality, when they tend to blame themselves and when they have no one to talk to or help with practical challenges or problems.
Social environments (home, school, friends, social, work) can also play a significant role; it is important to be surrounded by positive, calm and caring people, at least most or half of the time.
Events or personal experiences can trigger depression, such as a loss or moving to a new school. The meaning (as assigned by others or self assigned - how you make sense of it) and context of the loss or trauma can be very important. It is often helpful to think about any stressful event in terms of what happened before, what happened during, and most importantly, what happened afterwards (responses of responsible parties, the public, the community or loved ones for instance).
There also appears to be a link to chemical changes in the brain relating to Serotonin and Noradrenaline, and certain areas of the brain appear play a more significant role than other areas for instance the basal ganglia, limbic system and medial thalamus. Research is ongoing and the 'chicken and egg challenge' (are the identified neurological, biological or chemical changes risks or causes for depression, or due to depression) often remains.
Depression, like most mental health disorders, is a complex disorder, often with multiple and complex causes, but with the right support, the outcome or prognosis in children and young people can be very good.
Some young people feel depression is a sign of weakness; that they are somehow at fault, to blame, responsible for "getting depressed" and feel that they should have been stronger for their parents, siblings or friends. This is inaccurate and children and young people will need support regarding these beliefs and feelings.
Medical problems and certain medications can also cause Depression, and medical problems and certain side-effects of medications can also look just like Depression in a person that is not depressed. It is always important to see a medical doctor and ensure that any medical problems (organic causes) that might explain or cause mental health symptoms have been considered. Consultant Child Psychiatrists often work closely with GPs to consider physical health and ensure that physical (or organic) causes are ruled out, before mental health diagnoses or neurodevelopmental diagnoses (such as ADHD or ASD) are made.
Non-Medical Differential Diagnoses (Problems that can look similar to Depression)
Anxiety disorders such as Generalised Anxiety Disorder, OCD or PTSD
Affective and psychotic disorders such as Schizophrenia
Neurodevelopmental disorders such as ADHD and Autism Spectrum Disorder
Abuse
This list is not comprehensive.
Medical Differential Diagnoses (Medical problems that can look like Depression)
Trauma such as brain injuries
Infections such as Hepatitis A, Mononucleosis or other chronic infections
Nutritional concerns for instance relating to Vit B12, Folate, Niacin, Thiamine, Vit C
Neurological problems or disorders such as Wilson's disease, Migraines or Epilepsy
(Remember many types of Epilepsy can occur such as TLE, not all are visible convulsions)
Cardiovascular and cardiopulmonary problems such as relating to blood pressure or oxygenation
Inflammatory and autoimmune disorders such as SLE
Endocrine concerns such as relating to thyroid or adrenal problems, or Diabetes Mellitus
Metabolic and biochemical concerns for instance relating to uremia or calcium levels
Haematological problems such as anaemia or porphyria
Neoplasms
Medication such as used for pain, infections or to manage blood pressure or cardiac disease
This list is not comprehensive.
Medical Problems causing Depression / Liaison Psychiatry
It is not uncommon for any medical problem, illness or disorder, including the medical problems and medication listed above, to cause mental health problems including depressive illnesses and anxiety disorders in children and young people.
The relationship between physical health and mental health can be complex; it is important to ensure that medical causes have been considered and ruled out prior to making a diagnosis of a mental illness or neurodevelopmental disorder.
Comorbidities
Research indicates that up to 40% of children with Depression may present with comorbidities. Comorbidities may include anxiety disorders, behavioural disorders, ADHD or illicit drug use or alcohol abuse (or use in children). Child Psychiatrists routinely monitor for comorbidities and complications.
How is depression diagnosed?
Depression in children and young people should only be diagnosed and treated by professionals with specialist experience in Child and Adolescent Psychiatry, such as Child & Adolescent Psychiatrists / Consultants in Child and Adolescent Psychiatry.
Diagnosis is usually based on a thorough clinical interview, taking into account a broad range of different factors. As with mental health assessments, assessment for depression often also includes interviewing family members and obtaining additional information from schools or any other helpful sources.
Depression in children and adolescents often presents different to Depression in adults
How do professionals treat depression?
Most Child Psychiatrists will try to avoid medication, especially if the depression is mild or moderate.
Psychotherapy / psychological therapies (talking therapies) can be very helpful. Young people often benefit significantly from a 'safe space' to talk and from learning skills to manage social and mental health difficulties. Professionals with experience in psychotherapy in children will offer to meet with children and young people on a regular basis, usually once a week for an hour. Family sessions or family therapy to support families and help families to support children are usually recommended.
It is important to know that a variety of psychological therapies / psychotherapies exist and it is important to discuss the options (what is available, what you feel you would prefer and what the research evidence says about the various therapies) with your therapist. It might be helpful to ask your therapist what her/his interest, training and experience is regarding the specific therapy that you are interested in or that has been suggested.
Therapies that may be helpful to treat Depression includes cognitive behavioural therapy (CBT), cognitive analytical therapy (CAT), psychodynamic therapy, creative therapies, group therapy and systemic family therapy.
Most importantly though, if you don't have a good rapport / feel comfortable with your therapist, it is very important to share this information, because this is a significant determining factor in whether your therapy will be helpful and successful - your therapist will want to know, will not feel offended or hurt and will recognise that sometimes two people don't have a good rapport, it is most often not personal. It is also important to say if you feel uncomfortable with the type or style of therapy after a few sessions and to discuss this with your therapist if this is the case. Your therapist's first priority will be that you move forward, so do feel free to share your feelings openly.
Social or practical intervention is also an important component of treatment. Involving children in normative, enjoyable, meaningful activities after school hours with non-delinquent peers and adults with similar interests, provides children with the opportunity to learn skills, achieve goals and develop from an emotional, social, cognitive and physical point of view. The environment at home, school, work or in the community is also an important factor.
It is sometimes necessary to consider antidepressant medication, for instance, when psychotherapy alone has not helped and symptoms have not improved, continue to deteriorate and/or cause significant distress and impairment.
Child psychiatrists will consider prescribing medication such as Fluoxetine after carefully weighing the risks and benefits of the medication with you. Medication requires close monitoring for side-effects by a specialist and you will have to visit the clinic regularly while your treatment is in progress. Child psychiatrists usually recommend that the medication is part of a comprehensive treatment package, which includes psychological therapies / psychotherapy, social and educational support, family work, family support and psycho-education.
Medication
Child Psychiatrists may use antidepressants, usually SSRI's, such as Fluoxetine, to treat depression in young people.
What are antidepressants used for? (This list is not comprehensive)
Moderate to Severe Depression (usually if therapy has failed or not caused much improvement)
Anxiety disorders such as PTSD and OCD
Eating disorders
What are some of the antidepressant options?
SSRIs (selective serotonin reuptake inhibitors)
SNRIs (serotonin and noradrenaline reuptake inhibitors)
TCA (tricyclics) - very rarely used in children and young people
MAOIs (monoamine oxidase inhibitors) - very rarely used in children and young people
Most Child Psychiatrists will agree on SSRIs as first line treatment for children and young people presenting with depression or anxiety disorders where medication is indicated. Child Psychiatrist will be able to provide you with more details regarding treatment options, benefits and risks.
Does antidepressant medication work?
Research indicates that more or less 50-60% of people with moderate to severe depression will present with improvement in presentation after 3 months of treatment compared to 25-30% on placebo. Several factors impact on prognosis, such as early diagnosis and intervention.
In children or young people where medication is indicated (for instance due to the severity of symptoms and psychotherapy not causing improvement) the best prognosis is associated with a combination of medication and psychotherapy.
How long does it take for antidepressants to work?
It usually takes up to 6 weeks for a response. Many children report a positive change sooner, although some children only report a positive change 12 weeks later. Marked inter-individual variability and tolerability have been noted with SSRIs and other antidepressant medication.
How long will treatment last?
Follow up is arranged regularly to check presentation and progress. Further to remission (no or significantly reduced symptoms for 8 weeks), the medication is usually continued for 6-12 months before it is gradually discontinued. The reason is to prevent relapse (another depressive episode following recovery). Relapse rates can be as high as 50-60%; it is important to take bio-psycho-social steps to prevent relapse. Child Psychiatrists usually agree a relapse prevention plan with children and families.
Is it easy to stop the medication?
Child Psychiatrists often recommend discontinuing antidepressant medication over 6-12 weeks to prevent 'discontinuation syndrome' (consideration is given to half-life of the medication - no relation to dependence or addiction). Starting and discontinuing psychotropic medication (medication that affects the brain) at a slow rate is often recommended. Psychotropic medication is usually started at a low dose and increased gradually, and then gradually reduced, before stopping. This provides the brain time to adapt to the change in the biochemical environment.
It is important to know that antidepressants are not addictive.
Discontinuation syndrome:
Flu like and/or gastro-intestinal symptoms
Shock like sensations, dizziness, headaches and/or sweating
Anxiety, irritability, agitation, low energy
How to treat discontinuation syndrome? Start the medication at a low dose again and reduce at a slower rate. It is important to make any change in medication, with the advice of your child psychiatrist.
Side-effects of antidepressant medication?
Most of the children we see do not experience side-effects, because the medication is started when indicated, at low dosage, slowly increased if indicated and regularly monitored.
Some children may experience mild side-effects such as nausea after the medication is started, which usually resolve within 1-2 weeks. It is however important to liaise with a doctor (your Child Psychiatrist or GP or a doctor in the Emergency Department) immediately regarding any concerns or side-effects when starting any medication. Your Child Psychiatrist will agree a treatment plan with you which will include 'action plans' for when concerns arise.
Some common side-effects:
Anxiety, agitation, irritability, appetite changes, sleep changes
Abdominal pain, dry mouth, nausea, vomiting, diarrhoea and/or constipation
Tremor (shaking), sweating
Some of the less common side-effects:
Blood pressure and heart rate changes, palpitations (feeling your heart beating fast) or dizziness
Tiredness, drowsiness, headaches, blurred vision, visual disturbances or sensitivity to light
Delayed urination, sexual dysfunction
Rash - IMMEDIATELY INFORM A MEDICAL DOCTOR BEFORE TAKING MORE MEDICATION
Behavioural changes and changes relating to risk:
SSRI's have been linked to a possible increase in suicidal thoughts and behaviour. Child Psychiatrists assess and monitor risk carefully and ask children and young people to inform their parents/carers immediately if they feel suicidal or more suicidal after medication has been started.
More or less 3-8% of children present with transitory mood changes (often silliness or restlessness) and parents often ask if this relates to Mania or Bipolar Affective Disorder. This is usually a response of disinhibition, rather than related to Mania, Hypomania or Bipolar Affective Disorder. Child Psychiatrists routinely assess for symptoms and signs of Hypomania, Mania and Bipolar Affective Disorder when they monitor children during follow up appointments; families will be informed of concerns and possible risks and warning signs will be discussed. It is important to know that antidepressant medication cannot cause Hypomania, Mania or Bipolar Disorder, the medication can only help to reveal it. Children and young people with Depression have a higher risk of developing Bipolar Affective Disorder.
Discuss the topic of medication, risks and benefits, as well as the different treatment options with your doctor.
Please know that some medications cannot be taken together, please speak to your pharmacist or doctor before taking other medication with your antidepressant medication.
If you are concerned about any possible side-effects or if you develop a rash or pruritis (itchiness), or feel unwell or suicidal, please consult with a doctor immediately, before taking more medication.
IMPORTANT
Parents and carers often ask how much "pressure" to apply to encourage or inspire young people to get out of the house and engage in their usual routine or try a new routine. It is important to weigh this with the level of impairment, distress and risk and discussing this with your Child and Adolescent Psychiatrist is important. The first step recommended is to have a discussion with the young person regarding what they feel would be helpful and negotiate a plan that suits everyone.
Parents and carers often experience significant stress when children and young people are presenting with medical or mental health difficulties. Parent, carer or family sessions for support, to discuss concerns and strategies and receive feedback regarding progress and risk are very important and this should be part of any treatment package.
Be aware of risk issues (ask children and young people directly whether they have any thoughts, ideas, intent or plans to harm themselves or others) and seek advice from your GP or local CAMHS (Child and Adolescent Mental Health Service) team immediately if you have concerns.
Please see Helpful Links for more information on support for children, young people, adults and families.
