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Diagnosing Depressive Disorders
 

DEPRESSION IN ADOLESCENTS

It is a common misconception that children do not have the capacity to become depressed, that their emotional history is too short or too uneventful to have reached the kind of impasse that they can't deal with. It used to be believed that children were too psychologically immature to even experience depression.

With teenagers, however, "depression" has long been regarded as a rite of passage through adolescence. The teen years tend to be emotionally turbulent, even for those who come from stable and supportive homes, who do well in school and have a solid circle of friends.

While healthcare professionals do recognize that the diagnostic criteria for depression are the same for children and teenagers as that for adults, these age groups tend to express the typical hopelessness, apathy and withdrawal in different ways, tending more toward anger, irritability, trouble getting along with others, notably parents and teachers, and basically disruptive behaviour. Depression often exists in conjunction with other disorders, including social or behavioural problems. To make matters more difficult, parents and schools have lagged in their acceptance that depression in this age group is a reality.

Suicide
The rate of suicide is the most sobering aspect of depression in children and teenagers. In Canada, the suicide death rate for teenage men has increased fourfold from 5.3 to 23.0 per 100,000 between 1960 and 1991; for teenage women, the rate increased from 0.9 to 4 per 100,000 in the same period. For 10 to 14 year-olds, the rate quadrupled from 0.6 to 2.4 per 100,000.

Risk factors for teen suicide include delinquency, drug abuse, social problems, divorce, abuse, and parental neglect. Surveys have revealed that the key factor in teen suicide seems to be lack of hope for the future. Young people have also indicated that they experience a high level of stress, feel lonely and emotionally distressed, have problems with relationships, and suffer from low self-esteem. One of the things that distinguishes the conceptual abilities of children and teenagers from that of adults is that they think primarily in the present and very short-term future, and are therefore often unable to see past a breakup with a girlfriend, or a difficult school year, for example.

 

Diagnosing Depression in Adolescents
Diagnosing depression in adolescents is notoriously difficult for a number of reasons:

1. Adolescents are not likely to spontaneously discuss their depression and if they do, they usually refer to it obliquely. More commonly, it is the parent who is concerned and who may have to be relied upon to provide historical details.
2. Depressed adolescents are prone to have comorbid psychiatric disorders, the most likely being anxiety. The first episode of bipolar affective disorder and schizophrenia often present in adolescence (at least in males); moreover, the first episode of bipolar affective disorder often appears as psychosis. Hence, if an adolescent presents with psychosis for the first time, the diagnosis of bipolar affective disorder should be considered.
3. Physicians may be less attentive to symptoms of depressive illness and suicidal tendencies in adolescents, possibly because it is assumed that depressed adolescents are merely going through the "normal" ups and downs of teenage years.

 

 

 

 

 

 

 

 

 

 

Depression In Adolescents: Key Clinical Features

• Mood swings are more intense than those associated with adolescent turmoil and the tendency to rage increases.
• Delayed puberty may be a sign of an eating disorder or, if accompanied by anorexia and weight loss; depression. Hence, depression should enter into the differential diagnosis when puberty is delayed.
• Normal adolescent tendencies towards self-consciousness and self-doubt are intensified.
• Development of abstract thinking, which normally occurs around the age of 12, is delayed, and it may disappear in older adolescents who could previously think in abstract terms.
• Difficulties in concentration may translate into avoidance or inability to finish school work.
• Feelings of low self-esteem are intensified and depressed teens may express this by saying they are stupid or ugly or that nobody likes them. Depressed teens also tend to focus on perceived physical imperfections as the cause of all their problems and will fixate on the imperfection to a disproportionate degree.
• Antisocial behaviour in adolescents who are not normally antisocial may include skipping school, stealing, fighting, traffic violations and irritable behavior in class.
• Alcohol and drug abuse is common, especially marijuana use.
• Depressed adolescents show no interest in dating or sex, although occasionally, they may become promiscuous as a defense against depression.
• Depressed adolescents appear pale and tired and lack energy. They commonly complain of headaches, stomach aches and other vague symptoms.

 

Please see:

Section IV: "Depression in Special Populations"
CANMAT – Guidelines for the Diagnosis and Pharmacological Treatment of Depression
(1st Edition Rev., 1999)
P. 45

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Over one million Canadians suffer from some form of depressive illness.