"Take Charge of the Care of Your Child"

        The National Institute of Mental Health estimates that at least 2.5 percent of children under the age of 18 (1.8 million children) are “severely depressed.”  The American Academy of Child and Adolescent Psychiatry places the number at 5 percent (3.4 million).  Some published authorities believe that depression remains severely under-diagnosed and that one in four children will experience a severe episode of depression by their 18th birthday.  (Fassler & Dumas, Help Me, I’m Sad: Recognizing, Treating and Preventing Childhood and Adolescent Depression, p. 2).  Depression can be a very dangerous illness:
        A number of epidemiological studies have reported that up to 2.5 percent of children and up to 8.3 percent Ink Blotof adolescents in the U.S. suffer from depression . An NIMH-sponsored study of 9- to 17-year-olds estimates that the prevalence of any depression is more than 6 percent in a 6-month period, with 4.9 percent having major depression . In addition, research indicates that depression onset is occurring earlier in life today than in past decades. A recently published longitudinal prospective study found that early-onset depression often persists, recurs, and continues into adulthood, and indicates that depression in youth may also predict more severe illness in adult life . Depression in young people often co-occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders,  and with physical illnesses, such as diabetes 
Suicide. Depression in children and adolescents is associated with an increased risk of suicidal behaviors . This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse . In 1997, suicide was the third leading cause of death in 10- to 24-year-olds . NIMH-supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may commit suicide in the young adult years. Consequently, it is important for doctors and parents to take all threats of suicide seriously.  National Institutes of Mental Health, “Depression in Children and Adolescents.” 
        Research reveals “that children with mood disorders like depression are more than five times more likely to attempt suicide than children not affected by such problems.”  (Fassler, David G., M.D. and Dumas, Lynne S., Help Me, I’m Sad: Recognizing, Treating and Preventing Childhood and Adolescent Depression,  p. 103; Cytryn, Leon, M.D. and McKnew, Donald, M.D., Growing Up Sad: Childhood Depression and Its Treatments, p. 75; Jamison, Kay Redfield, Night Falls Fast: Understanding Suicide, p. 114).  Psychopathology is necessary for serious suicidal behaviors to occur.  Psychological autopsy studies have consistently found that over 90 percent of all completed suicides in all age groups are associated with psychopathology, with mood disorder the most frequently reported in both men and women.  (Jacobs, Brewer & Klein-Benheim, “Suicide Assessment,” pp. 9, 45, Chapter 1 of The Harvard Medical School Guide to Suicide Assessment and Prevention, Douglas G. Jacobs, M.D., editor.  Hereinafter the Harvard Guide; Jamison, p. 245).
        Nevertheless, depression among suicide victims has been frequently found to be undiagnosed, untreated or undertreated.  One study found that only 29 percent of suicide victims who were depressed were receiving adequate antidepressant or lithium treatment at the time of their suicide. (Id.).  Untreated, depression often has an accelerating course in which episodes become more frequent and severe.  (NIMH).
        Of course, the "good news" is that most people suffering from depression, including children and adolescents, do not commit suicide.  But because suicide is irreversible, and is not always clearly telegraphed in advance by either words or behavior (threats or attempts), any seriously depressed person should be considered at risk.  In any event, depression can be a crippling illness at any age and, even if a victim is functional, limits enjoyment and darkly colors life.  Depression is a treatable illness.  Society should view it as such.
        According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (“DSM-IV”), the symptoms of major depression are:
        1.   Persistent sad or empty mood, either by patient’s report or by observation of others.  In children and adolescents, this can be irritable mood.
        2.    Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (again, as either reported by the patient or as observed by others). 
        3.    Significant change in appetite or body weight.
        4.   Difficulty sleeping or oversleeping (“insomnia” or “hypersomnia”).
        5.    Physical slowing or agitation as observed by others.
        6.    Fatigue or loss of energy.
        7.    Feelings of worthlessness or inappropriate guilt.
        8.    Difficulty thinking or concentrating, or indecisiveness (again, as either reported by the patient or as observed by others).
         9.   Recurrent thoughts of death or suicide.
 Id. at p. 327.
        The DSM-IV recommends a diagnosis of major depressive disorder if an individual has five or more of the above symptoms during the same two-week period. Another prominent authority suggests that “clinical depression is a combination of these symptoms which persist for longer than three weeks and cause failure in the person’s environments of home, work (school) or play.”  (Weinberg, M.D., Harper, M.D., Emslie, M.D. & Brumback, M.D., “Depression and Other Affective Illnesses as a Cause of School Failure and Maladaption in Learning Disabled Children, Adolescents and Young Adults,” Chapter 15, Secondary Education and Beyond. 
         The two most important symptoms of depression are a dysphoric mood and anhedonia.  In a dysphoric mood, a child feels sad, blue, hopeless, worried and irritable.  A child suffering anhedonia lacks interest or takes no pleasure in most usual activities, such as sports, hobbies or interactions with friends of family. (Cytryn & McKnew, p. 147).  This view reflects the DSM-IV criterion that diagnosis of depression requires the presence of at least one of these two symptoms.
        Weinberg, et al., agrees that a dysphoric mood is required for depression, but believes that self-deprecatory ideation, rather than anhedonia, is essential for a diagnosis of depression.  Self-deprecatory ideation is feelings of being worthless, useless, or guilty.  Weinberg would, in addition, require the patient to exhibit four or more other symptoms among agitation, sleep disturbance, change in school performance, diminished socialization, change in attitude toward school, somatic complaints, loss of usual energy and unusual change in appetite of weight.   (Weinberg, et al., p. 2).  Agitation includes irritability, sudden anger and difficulty getting along with others.  The most common sleep disturbance is trouble falling asleep.  Change in school performance is characterized by complaints from teachers of daydreaming, poor concentration, inattentiveness, incomplete homework, and consequent drop in grades.  “Diminished socialization” is defined the same as anhedonia.  (Id.)
        Most depressed young people will be failing in school,  will be difficult to live with at home, and will drop out of extra-scholastic pursuits.  The depressed individual’s judgment deteriorates, interests wane, and failure occurs. Weinberg, et al., p. 2.
        Another very strong link to childhood depression and to suicide is a history of depression in the family,

FAMOUS PEOPLE WHO WERE DEPRESSED

      Many people have achieved great things while battling depression.  A list of some follows.  Some people wrongly romanticize depression, pointing to people such as these and crediting their depression as giving them special insights.  This is wrong.  Instead, we should ask:  How much more could these talented people have done if depression had not drained some of their energy and enthusiasm?  Could Lincoln have won the Civil War in three years instead of four?  How many more symphonies or great books could the composers and authors have created?  We will never know.  But we do know depression robs people of talent, ambition and time.  It is no blessing. 

Abraham Lincoln: Civil War president                         

Mike Wallace: 60 Minutes correspondentPresident Abraham Lincoln suffered from depression
Dick Cavett: Late night talk show host

Georgia O’Keefe: Artist of Southwestern themes
Sylvia Plath: Poet
Nikolai Gogl: Author
Henrik Ibsen: Playwright
Gustav Mahler -- Composer
William Inge: Playwright
Rod Steiger: Actor
William Faulkner: NovelistMark Twain, famous author who suffered from depression
Ernest Hemingway: Novelist
Mark Twain: Novelist/humorist
David Bohm: Physicist
Sergey Rachmaninoff: Composer
Billy Joel: Entertainer
Charles Dickens: Author
Leo Tolstoy: Author
Boris Yeltsin: Russian Premier
Buzz Aldrin: Second man on the moon.
Drew Carey: Entertainer
Harrison Ford: Actor
Jim Carrey: Actor
William Styron: Author     Cole Porter, famous composer who suffered from depression
Winston Churchill: British Prime Minister, author
Terry Bradshaw: Football star, broadcaster
Franz Kafka: Author
Cole Porter: Composer
Princess Diana: Royalty
You can find many more lists on the Web. For example, at
http://www.mixednuts.net/depression-famous.html or at
http://depression.about.com/od/famous/Famous_People_With_Depression.htm

especially in the mother.  Researchers are increasingly certain that genes play an important role in vulnerability or predisposition to depression and other severe mental disorders. (NIMH; Cytryn & McKnew, pp. 74, 116).  The risk of depression among children of a depressed parent is as high as 30 percent by the end of adolescence (Weinberg, et al., places the range at 30-40 percent).  That means nearly one in three children of depressed parents are likely to suffer depression.  (Cytryn & McKnew, pp. 109-110; Weinberg, et al., p. 5).  Alcoholism is often present in the extended families of depressed children. (Ingersoll & Goldstein, p. 74).  Major psychological disorders, which are associated with genetic transmission, also increase the risk of suicidal behavior.  These include mood disorders and alcoholism.  (Mann & Arango, “The Neurobiology of Suicidal Behavior,” Chapter 6, p. 99, Harvard Guide).  “For those individuals with a high genetic load for depression little or no environmental stressors are needed.  These individuals will have spontaneous episodes of affective illness throughout their lives.”  (Weinberg, et al., p. 7). 
        Poor coping skills have been associated with suicide in school-age children.  Such children “are unable to produce alternative problem-solving strategies, resulting in diminished flexibility in meeting life’s challenges.  Decreased problem solving and poor social skills have also been associated with suicidal behavior in adolescents.”  Although poor school performance is a risk factor (for suicide and depression), low IQ is not.  “This suggests that it is the level of functioning rather than the underlying capacity that connotes risk.”  (Goldman & Beardslee, “Suicide in Children and Adolescents,” Chapter 24, p. 427, Harvard Guide; Shamoo, Tania K. and Patros, Philip, I Want to Kill Myself: Helping Your Child Cope with Depression and Suicidal Thoughts, p. 82).  Suicide-vulnerable individuals lack self-regulating capacities and have difficulty keeping a sense of internal composure.  (Jacobs, Brewer & Klein-Bonhem, “Suicide Assessment,” Chapter 1, p. 14, Harvard Guide).
        The depressed child often will be unable to tolerate frustration and may respond to even minor provocations with angry outbursts.  “Irritable mood is usually more apparent at home than in other settings: many depressed youngsters who are explosive at home and seem to go out of their way to pick fights with family members are able to control themselves in school and other public settings.”  Children with such Oppositional Defiant Disorder can be quite obedient and controlled outside the home.  (Ingersoll & Goldstein, pp. 5, 35).
        Puberty, which generally begins between the ages of twelve and fourteen, coincides with the first significant rise in the rate of suicide.  “It brings with it a whirlpool of hormones and a steady increase in the prevalence of major psychiatric disorders.  (Jamison, p. 202).
        Depression may appear as ADHD, but should be treated with an antidepressant rather than a stimulant drug such as Ritalin (or Adderall).  “The link between learning disabilities and depression is strong.  These disorders share many symptoms, such as decline in school grades, a short attention span, difficulty paying attention in class, and a lack of interest in school.  What’s more, learning disabilities can lead to depression.”  (Fassler & Dumas, pp. 62, 71).  ADHD “seems to be a high risk for depressive illness.”  Cytryn & McKnew, p. 113).  Twenty to 30 percent of youngsters diagnosed with depression also are diagnosed with ADHD.  (Ingersoll and Goldstein, p. 35).  Weinberg, et al., puts the number at 60 to 80 percent. (p. 7).  DSM-IV agrees that ADHD and other disorders are frequently associated with major depression.  (DSM-IV, pp. 324-25).  Some authorities opine that ADHD usually is an inappropriate diagnosis for children who have average to good academic records before the age of seven, and that later learning problems typical of ADHD actually are mainly symptomatic of depression. (Shamoo & Patros, p. 17; Ingersoll & Goldstein, p. 35).
We have reproduced a short test for depression which can be administered to your child.    See the Depression Test for Children by clicking here.  We also have provided a test for ADHD, which is frequently mistaken for depression or bipolar disease.  Click here.

We especially welcome submissions to be posted to the site, including more information about childhood depression, personal stories that might help others addressing this difficult subject, and news and political developments on children's mental health.  Send them to webmaster@depressedchild.org. 

 
[1]  Weinberg, et al., recommend first generation antidepressants, tricyclics, for children and young adolescents, although third generation antidepressants (SSRIs) may also be used.  They also recommend use of  SSRIs and tricyclics in combination.  Prior treatment response of family members suffering depression is one factor in selection of the proper medication.  The Weinberg article was written in  1995 and therefore fails to account for more recent testing.  (Weinberg, et al., pp. 8-9).

DISCLAIMER:  Unless otherwise indicated, all commentary and information on this web site is provided by persons who have no formal training in medicine or mental health.  You should weigh the information and comment on this site in consultation with a mental health professional.