Depressive disorders: Screening and Risk Factors

Screening
There are several tools that are useful for screening children and adolescents for possible depression. They include the Children's Depression Inventory (CDI) for ages 7 to 17; and, for adolescents, the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression (CES-D) Scale. When a youngster screens positive on any of these instruments, a comprehensive diagnostic evaluation by a mental health professional is warranted. The evaluation should include interviews with the youth, parents, and when possible, other informants such as teachers and social services personnel.

Risk Factors
In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys to develop depression. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.

Other risk factors include:

• Cigarette smoking
• Stress
• A loss of a parent or loved oneBreak-up of a romantic relationship
• Attentional, conduct or learning disorders
• Chronic illnesses, such as diabetes
• Abuse or neglect
• Other trauma, including natural disasters
• Treatment
  

Treatment for depressive disorders in children and adolescents often involves short-term psychotherapy, medication, or the combination, and targeted interventions involving the home or school environment. There remains, however, a pressing need for additional research on the effectiveness of psychosocial and pharmacological treatments for depression in youth. While data from adults indicate the need for maintenance treatment after episode recovery in order to prevent recurrences, the value of such treatment in children and adolescents has yet to be determined through research.

Psychotherapy. Recent research shows that certain types of short-term psychotherapy, particularly cognitive-behavioral therapy (CBT), can help relieve depression in children and adolescents. CBT is based on the premise that people with depression have cognitive distortions in their views of themselves, the world, and the future. CBT, designed to be a time-limited therapy, focuses on changing these distortions. An NIMH-supported study that compared different types of psychotherapy for major depression in adolescents found that CBT led to remission in nearly 65 percent of cases, a higher rate than either supportive therapy or family therapy. CBT also resulted in a more rapid treatment response.

Another specific psychotherapy, interpersonal therapy (IPT), focuses on working through disturbed personal relationships that may contribute to depression. IPT has not been well investigated in youth with depression; however, one controlled study found that IPT led to greater improvement than clinical contact alone.
Continuing psychotherapy for several months after remission of symptoms may help patients and families consolidate the skills learned during the acute phase of depression, cope with the after-effects of the depression, effectively address environmental stressors, and understand how the young person's thoughts and behaviors could contribute to a relapse.

Medication. Research clearly demonstrates that antidepressant medications, especially when combined with psychotherapy, can be very effective treatments for depressive disorders in adults. Using medication to treat mental illness in children and adolescents, however, has caused controversy. Many doctors have been understandably reluctant to treat young people with psychotropic medications because, until fairly recently, little evidence was available about the safety and efficacy of these drugs in youth.

In the last few years, however, researchers have been able to conduct randomized, placebo-controlled studies with children and adolescents. Some of the newer antidepressant medications, specifically the selective serotonin reuptake inhibitors (SSRIs), have been shown to be safe and efficacious for the short-term treatment of severe and persistent depression in young people, although large scale studies in clinical populations are still needed. So far, there are two controlled studies showing efficacy of fluoxetine and paroxetine, respectively. It is important to note that available studies do not support the efficacy of tricyclic antidepressants (TCAs) for depression in youth.

Medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy, those who are unable to undergo psychotherapy, those with psychosis, and those with chronic or recurrent episodes. Following remission of symptoms, continuation treatment with medication and/or psychotherapy for at least several months may be recommended by the psychiatrist, given the high risk of relapse and recurrence of depression. Discontinuation of medications, as appropriate, should be done gradually over 6 weeks or longer.

Talking With Parents

It is very important for parents to understand their child's depression and the treatments that may be prescribed. Physicians can help by talking with parents about their questions or concerns, reinforcing that depression in youth is not uncommon, and reassuring them that appropriate treatment with psychotherapy, medication, or the combination can lead to improved functioning at school, with peers, and at home with family. In addition, referring the youth and family to a mental health professional and to the information resources listed at the back of this publication can help to enhance recovery.

National Institute of Mental Health