Depression and Suicide in Children and Adolescents

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In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder.

Because mood disorders such as depression substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for clinicians who deal with the mental health problems of children and adolescents. The incidence of suicide attempts reaches a peak during the midadolescent years, and mortality from suicide, which increases steadily through the teens, is the third leading cause of death at that age (CDC, 1999; Hoyert et al., 1999). Although suicide cannot be defined as a mental disorder, the various risk factors—especially the presence of mood disorders—that predispose young people to such behavior are given special emphasis in this section, as is a discussion of the effectiveness of various forms of treatment. The evidence is strong that over 90 percent of children and adolescents who commit suicide have a mental disorder, as explained later in this section.

Major depressive disorder is a serious condition characterized by one or more major depressive episodes. In children and adolescents, an episode lasts on average from 7 to 9 months (Birmaher et al., 1996a, 1996b) and has many clinical features similar to those in adults. Depressed children are sad, they lose interest in activities that used to please them, and they criticize themselves and feel that others criticize them. They feel unloved, pessimistic, or even hopeless about the future; they think that life is not worth living, and thoughts of suicide may be present. Depressed children and adolescents are often irritable, and their irritability may lead to aggressive behavior. They are indecisive, have problems concentrating, and may lack energy or motivation; they may neglect their appearance and hygiene; and their normal sleep patterns are disturbed (DSM-IV).

Despite some similarities, childhood depression differs in important ways from adult depression. Psychotic features do not occur as often in depressed children and adolescents, and when they occur, auditory hallucinations are more common than delusions (Ryan et al., 1987; Birmaher et al., 1996a, 1996b). Associated anxiety symptoms, such as fears of separation or reluctance to meet people, and somatic symptoms, such as general aches and pains, stomachaches, and headaches, are more common in depressed children and adolescents than in adults with depression (Kolvin et al., 1991; Birmaher et al., 1996a, 1996b).

Dysthymic disorder is a mood disorder like major depressive disorder, but it has fewer symptoms and is more chronic. Because of its persistent nature, the disorder is especially likely to interfere with normal adjustment. The onset of dysthymic disorder (also called dysthymia) is usually in childhood or adolescence (Akiskal, 1983; Klein et al., 1997). The child or adolescent is depressed for most of the day, on most days, and symptoms continue for several years. The average duration of a dysthymic period in children and adolescents is about 4 years (Kovacs et al., 1997a). Sometimes children are depressed for so long that they do not recognize their mood as out of the ordinary and thus may not complain of feeling depressed. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression6 (Kovacs et al., 1994). When a combination of major depression and dysthymia occurs, the condition is referred to as double depression.

Bipolar disorder is a mood disorder in which episodes of mania alternate with episodes of depression. Frequently, the condition begins in adolescence. The first manifestation of bipolar illness is usually a depressive episode. The first manic features may not occur for months or even years thereafter, or may occur either during the first depressive illness or later, after a symptom-free period (Strober et al., 1995).

The clinical problems of mania are very different from those of depression. Adolescents with mania or hypomania feel energetic, confident, and special; they usually have difficulty sleeping but do not tire; and they talk a great deal, often speaking very rapidly or loudly. They may complain that their thoughts are racing. They may do schoolwork quickly and creatively but in a disorganized, chaotic fashion. When manic, adolescents may have exaggerated or even delusional ideas about their capabilities and importance, may become overconfident, and may be“fresh” and uninhibited with others; they start numerous projects that they do not finish and may engage in reckless or risky behavior, such as fast driving or unsafe sex. Sexual preoccupations are increased and may be associated with promiscuous behavior.

Reactive depression, also known as adjustment disorder with depressed mood, is the most common form of mood problem in children and adolescents. In children suffering from reactive depression, depressed feelings are short-lived and usually occur in response to some adverse experience, such as a rejection, a slight, a letdown, or a loss. In contrast, children may feel sad or lethargic and appear preoccupied for periods as short as a few hours or as long as 2 weeks. However, mood improves with a change in activity or an interesting or pleasant event. These transient mood swings in reaction to minor environmental adversities are not regarded as a form of mental disorder.

Conditions Associated With Depression

Roughly two-thirds of children and adolescents with major depressive disorder also have another mental disorder (Angold & Costello, 1993; Anderson & McGee, 1994). The most commonly associated disorders are dysthymia (see above), an anxiety disorder, a disruptive or antisocial disorder, or a substance abuse disorder. When more than one diagnosis is present, depression is more likely to begin after the onset of the accompanying disorder, except when that disorder is substance abuse (Biederman et al., 1995; Kessler & Walters, 1998). This suggests that, in some cases, depression may arise in response to the associated disorder. In other instances, such as the co-occurrence of conduct disorder and depression, the two may arise independently in response to inadequate maternal supervision and control, raising the possibility that parental behavior may be a risk factor for both conditions (Downey & Coyne, 1990; Rutter & Sandberg, 1992; Harrington, 1994).

Prevalence

Major Depression

Population studies show that at any one time between 10 and 15 percent of the child and adolescent population has some symptoms of depression (Smucker et al., 1986). The prevalence of the full-fledged diagnosis of major depression among all children ages 9 to 17 has been estimated at 5 percent (Shaffer et al., 1996c). Estimates of 1-year prevalence in children range from 0.4 and 2.5 percent and in adolescents, considerably higher (in some studies, as high as 8.3 percent) (Anderson & McGee, 1994; Lewinsohn et al., 1994a; Garrison et al., 1997; Kessler & Walters, 1998). For purposes of comparison, 1-year prevalence in adults is about 5.3 percent (Murphy et al., 1988; Rorsman et al., 1990; Regier et al., 1993).

Dysthymic Disorder

The prevalence of dysthymic disorder in adolescents has been estimated at around 3 percent (Garrison et al., 1997). Before puberty, major depressive disorder and dysthymic disorder are equally common in boys and girls (Rutter, 1986). But after age 15, depression is twice as common in girls and women as in boys and men (Weissman & Klerman, 1977; McGee et al., 1990; Linehan et al., 1993).