Childhood Depression

The preponderance of literature on Depression over the past decade suggests that it is a very common, vastly under-diagnosed and usually under-treated problem. A tendency towards depression run’s in certain families, and the presence of depression in a child, especially if unrecognized or not treated, is a major risk factor for later substance abuse, behavior difficulties, academic problems, dropping out of school, teen pregnancy, and other risk-taking behaviors.

Depression looks different in a child than it does in a teenager or adult. Children are not able to articulate or even correctly identify/label their feelings of sadness. Therefore, those feelings come out in different ways – most typically in irritability, social/peer problems, behavior problems, inattention, and academic failure.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), American Psychiatric Association, 1994, (the “bible” of Psychiatry) a diagnosis of “major depression” in a child requires that at least 5 of the following 9 criteria be met for at least a 2 week period:

Depressed or IRRITABLE mood most of the day, nearly every day, as indicated by either subjective report OR observation by others.

Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day, as indicated by either subjective report OR observation by others.

Significant weight loss or gain, or decrease or increase in appetite nearly every day.

Insomnia or hypersomnia nearly every day.

Psychomotor agitation or retardation nearly every day observable by others.

Fatigue or loss of energy nearly every day.

Feelings of worthlessness or inappropriate guilt.

Diminished ability to think or concentrate, or indecisiveness, nearly every day, as indicated by either subjective report OR observation by others.

Recurrent thoughts of death, suicidal ideation without a specific plan, or specific plan for or attempt at committing suicide.

Nobody pretends to fully understand the causes of depression. It is clear, however, that it is a complex disorder which involves an INTERPLAY of psychodynamic and neurobiochemical factors. Much research over the past several decades points to the neurobiochemical factors as being MORE important than psychodynamic ones. This is supported by many different types of observations:

People prone to depression have lower levels of certain neurotransmitters (chemical messengers – specifically serotonin and norepinephrine) in both their brains and their bloodstreams, than do “normal” people. The tendency for depression to run in families is another big one, as is the tendency of depression to be a chronic remitting/relapsing lifelong disease.

There are certain people who will NEVER become depressed, no matter how bad a hand life deals them. There are other people who lapse into depression seemingly at the slightest life stress. What’s more, once the depression is begun in these people it tends to self-perpetuate, like a vicious cycle, long after the precipitating life event has passed. Breaking this cycle can be very difficult – and counseling/psychotherapy is notoriously INEFFECTIVE for many cases of depression. In general, antidepressant medications are far more effective in a far higher percentage of cases.

Most clinicians feel that a combination of both psychotherapy and medications is best – that the medications are often a prerequisite for making psychotherapeutic progress, while the psychotherapy in the long run is what allows you to eventually be weaned from medications. There have been several “Task Force’s” of both government and professional organizations in recent years which have issued reports/policy statements which have said, in essence, that antidepressant medications should be used more freely in this country, that the stigma surrounding them should be removed/debunked, and that primary care physicians (internists, family practitioners, pediatricians) should be better trained at recognizing depression and become more comfortable in prescribing these types of drugs. These groups have looked not just at the psychobiology of the issue, but very much at the prevalence in the population and the cost to society in terms of lost productivity, etc.

Finally, there is absolutely NO evidence linking physician-prescribed treatment with antidepressant medications to later substance abuse problems in any way, shape, or form. To the contrary, appropriate, timely “chemical” therapy of childhood psychiatric disorders (of all sorts) actually REDUCES the risk of later substance abuse. Sometimes antidepressant medications actually help substance abusing adolescents stop “using”. Antidepressants themselves are not addictive, and they produce no “high” (and therefore have little abuse potential themselves – unlike pain killers, anti-anxiety drugs, or, for that matter, Ritalin – all of which can be abused). This is evidenced by the fact that NONE of them are listed as “Schedule II controlled substances” by the U.S. D.E.A., which Valium, Codeine, and Ritalin all are.