Depression in Children and Adolescents

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Depression in children and adolescents is a mental health condition characterised by persistent sadness, loss of interest or pleasure in activities, and a range of emotional and physical symptoms. It affects the way young people think, feel, and behave, and can lead to emotional, functional, and social impairments. Depression is not just "feeling down" but a prolonged and intense emotional state that requires intervention, particularly when it starts to interfere with daily life.

Aetiology

Depression in children and adolescents can be caused by a complex combination of genetic, environmental, and psychological factors:

• Genetic predisposition: A family history of depression or other mental health disorders increases the risk.
• Biochemical factors: Imbalances in neurotransmitters such as serotonin, norepinephrine, and dopamine can contribute to depression.
• Psychological factors: Children with low self-esteem, a pessimistic outlook, or perfectionist tendencies are more prone to depression.
• Environmental stressors: Difficulties such as family conflict, bullying, abuse, academic pressure, and significant life changes (e.g., parental divorce) can trigger depressive episodes.
• Trauma or loss: Grief, loss of a loved one, or exposure to violence or trauma can precipitate depression in young people.

Pathophysiology

Depression is thought to involve dysfunction in the brain’s neurotransmitter systems, particularly those that regulate mood, such as serotonin, norepinephrine, and dopamine. Stressful life events can also trigger the activation of the hypothalamic-pituitary-adrenal (HPA) axis, leading to prolonged release of cortisol, which has been associated with depressive symptoms. Additionally, genetic vulnerabilities and environmental factors may influence brain structure and function, leading to mood regulation disturbances. Cognitive and emotional processing deficits, such as negative thought patterns and low self-esteem, further perpetuate depressive symptoms.

Risk Factors

• Family history: A family history of depression, bipolar disorder, or anxiety increases the likelihood of developing depression.
• Childhood trauma: Experiencing abuse, neglect, or other forms of trauma significantly raises the risk.
• Bullying and peer difficulties: Social isolation, bullying, or strained relationships can trigger depressive episodes in young people.
• Chronic illness: Chronic physical health conditions, such as diabetes or asthma, can contribute to depression.
• Academic pressure: Struggles with schoolwork or pressure to succeed can lead to emotional distress.
• Gender: Depression is more common in adolescent girls than boys, potentially due to hormonal, social, and psychological factors.

Signs and Symptoms

The signs and symptoms of depression in children and adolescents can vary from those seen in adults. Common symptoms include:

• Persistent sadness or low mood: A child may feel sad, hopeless, or tearful most of the time.
• Loss of interest or pleasure: A marked decrease in interest in previously enjoyable activities (e.g., hobbies, sports).
• Irritability: Children and adolescents with depression often exhibit irritability, frustration, or anger rather than sadness.
• Fatigue: Persistent tiredness or lack of energy, even after adequate rest.
• Difficulty concentrating: Problems with focus and decision-making, which may affect school performance.
• Sleep disturbances: Difficulty falling asleep, staying asleep, or oversleeping (hypersomnia).
• Appetite changes: Increased or decreased appetite, often leading to significant weight loss or gain.
• Feelings of worthlessness or guilt: Frequent self-criticism or excessive guilt over small mistakes.
• Social withdrawal: Isolation from friends, family, and activities, preferring to spend time alone.
• Thoughts of self-harm or suicide: In severe cases, children and adolescents may express thoughts of self-harm or suicide, which should be taken seriously.

Investigations

The diagnosis of depression is primarily clinical, based on a detailed history and mental state examination. Additional investigations may include:

• Screening tools: Tools such as the Children’s Depression Inventory (CDI) or PHQ-9 Modified for Adolescents may be used to assess the severity of depression.
• Physical examination: To rule out medical conditions that may contribute to mood changes (e.g., hypothyroidism, anaemia).
• Blood tests: Full blood count (FBC), thyroid function tests (TFTs), and metabolic panels may be performed to exclude underlying medical conditions.

Management

Management of depression in children and adolescents involves a combination of psychological therapy, social support, and in some cases, medication. In the UK, antidepressants are generally not prescribed for children under 18, except in severe cases and under specialist supervision.

Psychological Therapy:

• Cognitive-behavioural therapy (CBT): CBT is considered the first-line treatment for depression in children and adolescents. It helps young people challenge negative thought patterns and develop healthier coping mechanisms.
• Interpersonal therapy (IPT): IPT focuses on improving interpersonal relationships and communication, which can help alleviate depressive symptoms.
• Family therapy: Involves family members in the treatment process to address family dynamics that may contribute to the child’s depression.

Referral to Child and Adolescent Mental Health Services (CAMHS):

Children and adolescents with moderate to severe depression should be referred to CAMHS for specialised assessment and treatment. CAMHS provides multidisciplinary care, including access to psychologists, psychiatrists, and social workers.

Medication:

In the UK, antidepressants are not typically prescribed to children under 18, except in severe cases where therapy alone is insufficient. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, may be prescribed under the guidance of a child psychiatrist. Fluoxetine is the only SSRI licensed for use in adolescents in the UK.

School and Social Support:

• School-based interventions: Collaboration with schools is essential to provide support with academic and social pressures. Adjustments to workload or expectations may be necessary.
• Peer support: Encouraging positive peer relationships and group therapy can help reduce feelings of isolation.
• Parental support: Parents should be educated about depression and how to provide emotional support to their child.

Emergency Management:

Children or adolescents with suicidal thoughts or those who pose a risk to themselves should be referred for immediate crisis intervention and may require hospitalisation in severe cases.

References

1. NICE (2024). Depression in Children and Young People: Identification and Management. Available at: NICE Guidance
2. Royal College of Psychiatrists (2023). Child and Adolescent Mental Health: A Parent’s Guide. Available at: RCPsych
3. British Medical Journal (BMJ). (2022). Management of Depression in Children and Adolescents. Available at: BMJ