Recognizing and Treating Depression in Children and Adolescents

Julie A. Dopheide


Am J Health Syst Pharm. 2006;63(3):233-243. 

In This Article

Epidemiology and Clinical Course

An increasing body of knowledge confirms that depression is a common and persistent illness in youth, affecting 0.3% of preschoolers, 2% of elementary school-age children, and 5-10% of adolescents.[12,13] The rates of prepubertal depression are similar for boys and girls; however, depression rates double in females after puberty.[12,13] Hormonal and environmental influences are thought to contribute to the increased frequency of depression in female adolescents.[14] Rates of depression increase dramatically as children move into adolescence.[14] Comorbidities such as substance abuse and anxiety disorders increase the risk of depression by two- to threefold.[13,14] An estimated 10-20% of adolescents have had at least one major depressive episode by age 18 years.[13,14] One study of 9863 students age 10-16 years found that 29% of American Indian youth exhibited symptoms of depression, compared with 22% of Hispanic, 18% of Caucasian, 17% of Asian-American, and 15% of African-American youth.[14]

Untreated, a depressive episode can last seven to nine months, and approximately 50% of patients will relapse within five years of their first episode.[12,15] Depression compromises the developmental process, with associated difficulties with concentration and motivation,[15] leading to poor academic performance, impaired social functioning, poor self-esteem, and a higher risk of suicide.[5,12,14]

Clinical Presentation

Major depressive disorder has been validated in children as young as 3 years ( Table 1 ).[16,17,18] For example, preschoolers may persistently show suicidal or self-destructive themes in play, or parents and caregivers may notice that a physically healthy child is uninterested in play.[16] Depression in children 8 years or younger may not be recognized because this age group is less likely to verbalize the emotional symptoms of depression and more likely to display symptoms of anxiety (e.g., phobias, separation anxiety), somatic complaints (e.g., "my tummy hurts," "I don't feel good"), and auditory hallucinations.[17,18] Depressed children are irritable, have temper tantrums, and display other problem behavior (e.g., shouting, lack of interest in playing with friends).[18] Older children (age 9-12 years) talk about running away from home; display boredom, low self-esteem, guilt, or hopelessness; and have a fear of death. Compared with adolescents with depression, children with depression are less likely to suffer from delusions or make serious attempts to commit suicide.[18]

Depressed adolescents (age 12-17 years) display more sleep and appetite disturbances and are prone to reckless behavior, delusions, suicidal ideation and acts, and impairment of overall functioning.[18] Depressed teenagers have more behavior disturbances and fewer neurovegetative symptoms (e.g., low energy, psycho-motor slowing) than do adults with depression.[12,18]

When a child or adolescent displays new-onset depressive symptoms with or without psychosis, bipolar disorder should be seriously considered as a possible diagnosis.[19,20] Risk factors for bipolar disorder include a family history of the illness, a history of antidepressant-induced mania, and psychomotor retardation associated with the depressive symptoms.[19,20] It is important to screen for bipolar disorder in these patients because treatment with antidepressants is more likely to trigger mania in these individuals, thereby increasing the number or severity of suicidal behaviors.[20,21,22] If a diagnosis of bipolar disorder is confirmed, a mood stabilizer (e.g., lithium, valproate) should be initiated before adding an antidepressant to treat persistent depressive symptoms.[22]

Regardless of the presence of bipolar disorder, children and adolescents have a greater risk of developing antidepressant-induced manic conversion compared with adults.[21,22] A longitudinal study of 87,920 patients taking antidepressants for any reason found that 4,786 patients (5.4%) age 5-29 years developed manic conversion.[21] Prepubertal or peripubertal children age 10-14 years had twice the risk of manic conversion, approximately 10%.[21] In pediatric psychiatry clinics in the late 1980s and early 1990s, the rate of antidepressant-induced behavioral activation, hypomania, or mania was approximately 20-50%.[23] The higher rate was likely due to the inclusion of youth with bipolar disorder and the relatively higher starting dosages of antidepressants in older clinical trials.[22,23]


A depressed youth with no other psychiatric diagnosis is a rarity. Common comorbid conditions include attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), substance abuse, posttraumatic stress disorder (PTSD), dissociative states, and trauma-related hallucinations.[12] The presence of multiple comorbid conditions and psychosocial stressors increases the severity and chronicity of the depressive episode.[12,14] In addition, combinations of medications can increase the risk of adverse drug reactions and drug interactions.[23,24] An evaluation of treatments for depression in the community found that 44% of children prescribed antidepressants were taking a concomitant psychotropic medication.[10]


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