Populations

Depression in Kids

The illness robs youth of their childhoods - and the prospect of a decent adulthood.

Some 3.4 million Americans under 18 have severe depression, one in every 33 children, according to estimates, and a staggering one in every eight teens, most who go undiagnosed and untreated.

According to Cynthia Pfeffer MD of Columbia University, testifying at 2004 FDA public hearing into the safety and efficacy of antidepressants in kids:

Major depression affects approximately two percent of children, and four to eight percent of adolescents. By the time a youngster reaches age 18, there is a 20 percent prevalence rate for major depression. "Since prior to World War II, each successive generation seems to have a higher risk for major depressive disorder," she reported.

The rate of dysthymia (minor depression) is slightly lower and is often under-recognized, she went on to say. Seventy percent of youth with dysthymia break out into major depression, usually within two to three years of the onset of dysthymia. Compared to adults, adolescents have more behavioral problems. Psychotic depression occurs in 30 percent of youngsters with major depression. Atypical depression has not been studied in kids. Co-occurring disorders may be present in up to 90 percent of youth with major depression, including dysthymia, anxiety, disruptive behavior, and substance use.

The personal toll can be enormous: Homework not done, lessons not learned, ostracism by peers, alienation from family, run-ins with authority. A typical depressive episode can rage on for nine months or more, the length of a school year, enough time to brand a youth as undesirable and sabotage forever his or her brightest hopes and dreams. Six to 10 percent of kids with major depression have a protracted course, 40 to 60 percent relapse after remission, and 20 to 60 percent have recurring episodes after recovery.

The victim may retreat into his or her inner world or take comfort in alcohol or illegal drugs. Or the opposite may happen in the form of aggressive behavior that has neighbors dialing 911.

Ultimately, all too many seek the wrong way out: CDC data from 2001 found that 19 percent of high school students had seriously considered attempting suicide, nearly 15 percent had made plans to attempt suicide, and almost 9 percent had made a suicide attempt the preceding year. A 1993 nine-year study by Kovacs et al found children with major depression had a 74 percent rate of suicidal thinking and a 28 percent rate of suicide attempts. The percentages were about the same for those with dysthymia.

Since the 1950s, youth male suicide rates in the US increased three-fold. In 2000, 1,921 US kids under age 20 died by suicide, the third leading cause of death in our youth. Fortunately, there has been a sharp decline starting in 1994 and around the same time in other industrialized nations, possibly related to teens being prescribed SSRIs..

Until a short while ago, our society refused to admit to depression in our children, much less acknowledge they had anything to be depressed about. All too often, parents fail to recognize the symptoms or respond with ill-advised boot-in-the-backside remedies. According to a survey of near-suicides, parents perceived depression in their children only 13 percent of the time (versus 57 percent subsequently diagnosed).

Making matters worse is the fact that kids, ever sensitive to stigma, are not inclined to speak up. According to Harold Koplewicz MD of NYU, speaking at a 1999 White House Conference on Mental Illness: "Teenagers are never volunteering to be customers for mental health services."

That is, assuming these services are available. In many states Medicaid does not pick up the tab.

As to why kids get depressed, all the usual suspects are trotted out: the stresses and strains of modern life, working parents, broken homes. Poor kids are at greater risk due to more environmental stressors, but well-off kids are hardly immune. After a certain age, girls become far more likely victims in much greater numbers, probably due to concerns about their appearance and fitting in.

But the terrible truth is we simply don't know. Child psychiatry lags behind our knowledge of both psychiatry as a whole and other childhood illnesses, this despite the great need to find out how young brains work, which are not simply miniature replicas of our own.

Signs of Depression in Kids

Following are some of the danger signs, according to NAMI:

* Persistent sadness and hopelessness.
* Withdrawal from friends and from activities once enjoyed.
* Increased irritability or agitation.
* Missed school or poor school performance.
* Changes in eating and sleeping habits.
* Indecision, lack of concentration, or forgetfulness.
* Poor self-esteem or guilt.
* Frequent physical complaints, such as headaches and stomach aches.
* Lack of enthusiasm, low energy, or low motivation.
* Drug and/or alcohol abuse.

But wait. Before you rush your child to get treatment, there are things you should know: Early-onset depression often co-occurs with other disorders, such as attention deficit disorder or as a prelude to bipolar disorder. Prescribing an antidepressant in either of these cases may well send your child bouncing off walls.

Should Kids with Depression Take Antidepressants?

Antidepressants were designed for adult brains, but in Jan 2003, following two successful trials, the FDA approved Prozac for kids seven to seventeen, the first and only antidepressant indicated for such use. Prior to this, these drugs had been used "off label" for this population. Nevertheless, the FDA was worried about one of the trials that found the Prozac kids gained two pounds less and grew half-inch less after 19 weeks than those on placebos. Eli Lilly has promised to do more studies. Several other antidepressants have failed in clinical trials in children, and have raised concerns over their safety, resulting in two highly-publicized FDA public hearings in 2004 and a new black box warning on the product labeling (see article).

The reported safety data from the FDA and its UK counterpart, the MHRA, although spotty, revealed that 6.1 percent of the kids in the Prozac trials experienced hyperactivity, 3.1 agitation, and 2.6 had manic or hypomanic reactions (vs hardly any or zero in the placebo groups). Although the FDA did not connect these effects to suicidal behavior, in October 2004 it instructed manufacturers to warn on the product labeling that kids on antidepressants need to be carefully monitored as "there is concern that such symptoms may represent precursors to emerging suicidality."

An FDA analysis of 25 pediatric trials involving 4,000 patients found “out of 100 patients treated we might expect two to three patients to have some increase in suicidality due to short-term treatment ... that is beyond the risk that occurs with the disease being treated.”

But in a study published in the Oct 2003 Archives of General Psychiatry, researchers from Columbia University reviewed 588 case files of kids aged 10 to 19 and found that a one percent increase in antidepressant use was associated with a decrease of 0.23 suicides per 100,000 adolescents per year, suggesting that your depressed child is probably a lot safer on antidepressants than off them.

The best way to assess the benefits vs risks and ensure optimal meds care for your child is to consult a psychiatrist, ideally one with a specialty in pediatric psychiatry. At the FDA hearings, parents came forward numerous examples of primary care physicians who failed to warn parents of the potential adverse effects of these drugs and provide proper follow up. If a primary care physician is your only option, make sure he or she has some basic competence in treating kids for depression.

An informed parent working closely with a psychiatrist can greatly minimize the risk. Keeping a watchful eye out for strange behavior can be difficult with a teen - who are strange by definition - but when in doubt call your psychiatrist immediately.

A 2004 NIMH study of 439 youths found Prozac helped teens overcome depression far better than talking therapy, and that the greatest success came when the two treatments were combined. After 12 weeks, 43 percent responded to talking therapy, 61 percent to Prozac, and 71 percent to combination Prozac-talking therapy.

Even though other antidepressants have not been successful in pediatric clinical trials, it may be appropriate to prescribe them off-label to kids in certain situations. The FDA does not forbid the practice, but you are entitled to a clear explanation from your child's psychiatrist.

Parents have the power to make a huge positive difference. According to Los Angeles therapist Judith Harris, in an article in USA Today: "Kids who beat depression often have parents willing to listen with care and perhaps for the first time embrace a child who isn't the kid they hoped for."

Kids' Depression Guidelines for Parents

Following are some common sense guidelines for parents:

* Reassure your child. Let him know that you are there for him, that with proper treatment soon he will be feeling better.
* Let her know that depression is not her fault. Acknowledge she has a right to feel depressed.
* It's not your fault, either. You're not a bad parent because your child is depressed.
* Educate yourself thoroughly. Early-onset depression can be far more complex than adult depression and frequently co-occurs with other disorders or behaviors. Even the experts can be confused.
* Monitor your child's progress very carefully, especially for any antidepressant side effects and strange behavior.
* Inform your child's teachers. You need to have your school on the same page as you. Schools are obliged to make special accommodations for your child, if necessary, and can work with you on an Individualized Educational Program (IEP).
* Get your spouse involved. This is especially true if you are separated or divorced and you are the custodial parent. Marriage breakups are hard enough on children without one parent keeping the other one out of the loop.

The Surgeon General Weighs In

"The nation is facing a public crisis in mental health for infants, children and adolescents. Many children have mental health problems that interfere with normal development and functioning. In the United States, one in ten children and adolescents suffer from mental illness severe enough to cause some level of impairment. Yet, in any given year, it is estimated that about one in five children receive mental health services."

The above is from the 2001 Report of the Surgeon General’s Conference on Children’s Health.

"Too often," according to the Report, "children who are not identified as having mental health problems and who do not receive services end up in jail. Children and families are suffering because of missed opportunities for prevention and early identification, fragmented treatment services, and low priorities for resources."

The consequences can be enormous: "Approximately 50 percent of students labeled [with emotional or behavioral disorders] drop out of school; only 42 percent of those who remain graduate with a diploma. Post secondary outcomes are also poor, including multiple jobs, criminal behavior, and unemployment."

The Report draws on the testimony of 300 presenters and participants who gathered in Washington DC under the Surgeon General’s auspices in Sept 2000.

According to David Offord MD of McMaster University, cited in the Report, emotional and behavioral problems are the leading cause for lowering the quality of life in children: "No other set of conditions is close in the magnitude of its deleterious effects on children and youth ... "

Further, child mental disorders persist into adulthood. Seventy-four percent of 21-year-olds with mental disorders had prior problems.

But parents are faced with a plethora of rigid, conflicting, and arbitrary programs and laws that often leave their children out in the cold. According to the Report: "Very often the most in need do not get the services. Real parental involvement, and attention to family satisfaction, family practice and quality of life is often left to chance."

Most referrals from primary care physicians are for child psychologists, but average waiting time for an appointment is three to four months.

Meanwhile, in the schools, Steve Forness, Ed D of UCLA pointed out that children with mental health needs are usually identified only after their problems cannot be managed by their regular classroom teacher. According to one study of a group of 13-year-olds (one-third who were depressed), 6.5 years after their parents spotted a problem, the kids finally got the right services at age 10.

Neal Halfon MD, MPH., of UCLA, argued we are spending too little too late. According to the Report: "From a limited number of studies, mental health disorders in young children show similar prevalence rates to those found in older children. The catch is that you have to look more carefully to find them."

One obvious place to look is among the 22 percent of children age five and below who live in poverty, which in itself is a major risk factor for mental illness. Children in foster care use mental health services up to 15 percent more than other children in the Medicaid system.

Meanwhile, in the juvenile justice system, where many children with mental health problems end up, among a sample of 1,829 children, two-thirds tested positive for drugs. Nearly 20 percent of the sample had an affective disorder, and more than two-thirds of those with an affective disorder also had substance abuse or dependence. Nearly two percent of the sample have died, all violently.

"Early brain research," the Report warns, "tells us that the roots of emotional regulation and development, so crucial for life and school success, lie in the earliest relationships. Experience and some research tell us that too many young children are headed for trouble ... Absent systematic efforts to promote prevention, early intervention and relationship-based treatment for this age group we will simply create the ... juvenile justice and special education population of the future."

Updated Feb 15, 2008