WISCONSIN UNITED
for MENTAL HEALTH

In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder. Roughly two-thirds of children and adolescents with major depressive disorder also have another mental disorder, most commonly an anxiety disorder, a disruptive or antisocial disorder, or a substance abuse disorder. Most children with depression experience a recurrence.

The precise causes of depression are not known. Extensive research on adults with depression generally points to both biological and psychosocial factors. However, there has been substantially less research on the causes of depression in children and adolescents. Both major depressive disorder and dysthymic disorder are inevitably associated with personal distress, and if they last a long time or occur repeatedly, they can lead to a circumscribed life with fewer friends and sources of support, more stress, and missed educational and job opportunities.

Because mood disorders such as depression substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for clinicians who deal with the mental health problems of children and adolescents. The incidence of suicide attempts reaches a peak during the mid-adolescent years, and mortality from suicide, which increases steadily through the teens, is the third leading cause of death at that age. Although suicide cannot be defined as a mental disorder, the various risk factors—especially the presence of mood disorders—that predispose young people to such behavior are given special emphasis in this section, as is a discussion of the effectiveness of various forms of treatment. The evidence is strong that over 90 percent of children and adolescents who commit suicide have a mental disorder, as explained later in this section.

Major depressive disorder
Major depressive disorder is a serious condition characterized by one or more major depressive episodes, lasting from 7 to 9 months on average. Depressed children are sad, they lose interest in activities that used to please them, and they criticize themselves and feel that others criticize them. They feel unloved, pessimistic, or even hopeless about the future; they think that life is not worth living, and thoughts of suicide may be present. Depressed children and adolescents are often irritable, and their irritability may lead to aggressive behavior. They are indecisive, have problems concentrating, and may lack energy or motivation; they may neglect their appearance and hygiene; and their normal sleep patterns are disturbed. Associated anxiety symptoms, such as fears of separation or reluctance to meet people, and somatic symptoms, such as general aches and pains, stomachaches, and headaches, are more common in depressed children and adolescents than in adults with depression.

* The Depressed Child (AACAP Facts for Families)
* Red Flags (school-based depression awareness program by the Mental Health Association in Summit County, Ohio)

Bipolar disorder
Bipolar disorder is a mood disorder in which episodes of mania alternate with episodes of depression. Frequently, the condition begins in adolescence. The first manifestation of bipolar illness is usually a depressive episode. The first manic features may not occur for months or even years thereafter, or may occur either during the first depressive illness or later, after a symptom-free period.

Adolescents with mania or hypomania feel energetic, confident, and special; they usually have difficulty sleeping but do not tire; and they talk a great deal, often speaking very rapidly or loudly. They may complain that their thoughts are racing. They may do schoolwork quickly and creatively but in a disorganized, chaotic fashion. When manic, adolescents may have exaggerated or even delusional ideas about their capabilities and importance, may become overconfident, and may be “fresh” and uninhibited with others; they start numerous projects that they do not finish and may engage in reckless or risky behavior, such as fast driving or unsafe sex. Sexual preoccupations are increased and may be associated with promiscuous behavior.

* Bipolar Disorder in Children and Teens (AACAP Facts for Families)
* Child and Adolescent Bipolar Foundation

Dysthymic disorder
Dysthymic disorder is a mood disorder like major depressive disorder, but it has fewer symptoms and is more chronic. Because of its persistent nature, the disorder is especially likely to interfere with normal adjustment. The onset of dysthymic disorder (also called dysthymia) is usually in childhood or adolescence. The child or adolescent is depressed for most of the day, on most days, and symptoms continue for several years. The average duration of a dysthymic period in children and adolescents is about 4 years. Sometimes children are depressed for so long that they do not recognize their mood as out of the ordinary and thus may not complain of feeling depressed. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression.

Reactive depression
Reactive depression, also known as adjustment disorder with depressed mood, is the most common form of mood problem in children and adolescents. In children suffering from reactive depression, depressed feelings are short-lived and usually occur in response to some adverse experience, such as a rejection, a slight, a letdown, or a loss. In contrast, children may feel sad or lethargic and appear preoccupied for periods as short as a few hours or as long as 2 weeks. However, mood improves with a change in activity or an interesting or pleasant event. These transient mood swings in reaction to minor environmental adversities are not regarded as a form of mental disorder.


Treatment
Depression
Psychosocial interventions for depressed children and adolescents indicate great promise, with several types of cognitive-behavioral therapy for the child or adolescent leading the way. With respect to pharmacotherapy, new studies attest to the safety and efficacy of two SSRIs, fluoxetine (Prozac) and paroxetine (Paxil). These promising findings are being extended in the recently begun NIMH-funded Treatment of Adolescents with Depression study.

Combination Treatment Most Effective in Adolescents with Depression (NIMH 2004 Press Release)
Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers (NIMH 2006 Press Release)

Bipolar Disorder
Mania in bipolar disorder of children is also treated with lithium, although the relevant research on children lags behind that on adults. Only in recent years have researchers begun to study lithium in children and adolescents, with good clinical response. Lithium has recently proved to be more effective than placebo in treating adolescents who were bipolar and substance dependent. Lithium is therefore not recommended for families unable to keep regular appointments that would ensure monitoring of serum lithium levels and of adverse events. Patients who discontinue taking the drug have a high relapse rate.