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Depression in Childhood and Adolescence
Professor Carol Fitzpatrick is Professor of Child Psychiatry at University College Dublin, and a Consultant Child and Adolescent Psychiatrist at the Mater Hospital, Dublin, and The Children’s Hospital, Temple Street, also in Dublin. The following notes were taken at the August lecture, part of the Aware Monthly Lecture Series, which was delivered by Professor Fitzpatrick.
What do we mean by depression?
We all experience feelings of depression from time to time, for example, a lack of
enthusiasm or lack of affection. It is within the normal range of human emotion. In
one meaning of the word, depression is a normal response to failure, loss and life’s
disappointments. These feelings don’t last very long - maybe up to a few days.
However, Depressive Disorder
is quite different. The DSM criteria are a widely
used in recognising it.
The young person must have that type of depressed mood all day, or nearly all
day, as reported or observed. (Young people rarely say
they are depressed. Sometimes it shows more in anger, irritability or sadness and is often not recognised as depression. Some behaviours may suggest that the young person has an ‘attitude problem’.)
A loss of interest or pleasure in most activities of the day is felt. They may lose
interest in clubs, music and withdraw from family and friends, preferring to stay in their room. While teenagers may do this anyway, as they lose their childhood interests, for those who are depressed, it is with a greater degree than for other young people.
These are both core symptoms along with the following:
Disturbance in appetite and weight (either a decrease or increase)
Recurrent thoughts of death, suicide plans or attempts
Impaired concentration is very common. The young person may have been doing very well at school previously, but now may be finding things more difficult. In some cases, the teacher may feel as if the individual is not trying.
Between 30-50% of young people who experience a depressive disorder have significant thoughts of suicide. Many young men who die by suicide will have had
depressive disorders, which were unrecognised or untreated. However, suicide is still rare, while depressive disorders are common. It is therefore very important to recognise depression early and get treatment and support. Varying degrees of depression can be experienced – sometimes the person won’t eat and there is much weight loss, in which case hospital admission may be required. However, most cases can be managed without hospitalisation.
It is rare for one event to trigger a depressive episode. It is often a range of factors,
which come together. There has been research into genetic factors, and it is
acknowledged that depressive disorders can run in some families. What seems to
be inherited is a susceptibility to the illness. Some personality types are more likely
to suffer e.g. those who have an anxious, perfectionist or self-doubting personality
or those with low self-esteem. Difficult life experiences, which can contribute,
include abuse - physical, emotional or sexual; difficult family situations and
Drug & Alcohol Use
Ireland’s tolerance for high levels of alcohol use means it is difficult to separate
young people’s potentially dangerous drinking levels from the norm. Alcohol can
make people feel better initially, but a depressed mood may ultimately result. The
same applies to cannabis and continued use can lead to more serious depression.
Professor Fitzpatrick showed images of complex brain scans to illustrate the
structural changes in the brain occuring in depressive disorder. These illustrate a
number of noticeable changes, and these are likely to prove significant in years to
How common are Depressive Disorders?
Young people do not have the words or the language to express what they are
experiencing. We now know that very young children from the age of five or six can
experience depression, although it is rare. In an English study it was found that
among children in the community:
0.2% of 5-10 year olds were affected
1.8% of 11-15 year olds (equal in boys and girls)
4.5% of 13-15 year olds (more female than male)A north Dublin study found that 4.5% of 13-15 year olds had an unrecognised depressive disorder (equal in boys and girls).
Why is Depression important?
Depression is important due to the suffering and impairment of the individual and
the effect on that person’s relationships. If left unrecognised and untreated,
depression can result in suicidal behaviour and completed suicide. It can also be a
forerunner for recurrent depression and bipolar disorder.
Professor Fitzpatrick played some audio clips (from a recent study). Excerpts from three teenagers stories were included:
Jack: “I was sad and irritated over anything … I wouldn’t play basketball …wouldn’tinvite friends to the house … My Mam talked to me a lot … I felt pressure … Smallthings became bigger - I broke a glass and thought it was the end of the world. I’dfight with my brother.”
Brian: “My Grandad was abusing me. I saw a social worker and a therapist … I gotno information. I was glad I told even though it caused rows with my Mam and Dad… Then bullying at school. I told nobody. Tried suicide. Then hospital. But notready to talk. Couldn’t open up … As I got older things got better. Secondaryschool was better. The bullying faded away. There are people to help. I was gladwhen I was told it was depression. Now I’ve hope for my future. I have problemsbut have learned to deal with them better.
Linda: “My parents split up. I stayed in my room and cried in bed. I couldn’tconcentrate. I felt awkward with people my own age. In secondary [school], otherswere hanging out. I just went home and remained alone. Listened to loud music.
It’s a vicious circle.”
These extracts ‘tell it as it is’. Professor Fitzpatrick explained about the study and that the participants got a lot out of meeting with other people who had a similar experience to them. She finds it helpful to share these with others. It was noteworthy that family support was rated much more highly than support from any professionals, although these teenagers are often in conflict with their parents.
The vast majority of young people recover from depressive disorder. It often takes months or even up to two years. But are more at risk of a relapse? 40-60% do have a further episode of depression, but that means that 40-60% do not. The risk is higher if it has been the initial episode has been a bad one, if the person has an accompanying physical illness or if there is no family support.
If the depression is mild, the person may not require treatment. However,
recognising that they’re going through a rough time but will come through it on their
own is helpful. In moderate cases, the outcome is better with treatment. CBT
(Cognitive Behavioural Therapy) is getting much notice at the moment. It is easy to
evaluate. It’s in the here and now. It’s not trawling through your awful childhood. It’s
an active therapy. The young person is an equal partner with the therapist.
However, it’s not for everyone. Some young people are not able to be involved. A
number of studies suggest an SSRI e.g. Prozac and CBT together can be effective
for more severe depressive episodes.
Questions & Conflict regarding SSRIs
SSRIs are a group of anti-depressant medications. Common names include
Prozac, Cipramil and Lustral. Lustral is licensed for the treatment of Obsessive
Compulsive Disorder (OCD) in children. However, no anti-depressant medications are licensed for use in children (up to 18 years of age) in Ireland. This is mainly the case because of the expense involved in clinical trials to be undertaken by drug companies to have these products licensed. Some trials are being conducted in the US at the moment.
Doctors do have the discretion to prescribe any medication they deem necessary for their patient of any age. The Irish Medicines Board has acknowledged that depression can be a serious condition in children and that drug treatment may be necessary. They are currently working on guidelines and have issued a warning about the use of Seroxat as it increases the risk of agitation.
The FDA (Food and Drug Administration) in the US has reviewed the published and unpublished results of clinical trials. They found that among 2,200 children there were no suicides; SSRIs produced a small though definite risk of agitation and suicidal thoughts. Importantly, education around these side effects is imperative for the patient and their family.
The treatment of depression in young people involves much work. There are different approaches with a multi-model approach being the most recommended. Professor Fitzpatrick said that no prescription should be given on the first visit, and it is important to try to engage the person in some kind of therapy. Part of being depressed is a feeling that nothing can be done about it. If using SSRIs (anti-depressants), the risk, e.g. agitation and benefits should be explained and a plan to manage these together established. Acknowledgement of the support needs of parents is important.
* Professor Fitzpatrick’s book Coping with Depression in Young People
(co-written with John
Sharry) was published in 2004. It is available via mail order from Aware (see pg 24 of this
magazine) or online at www.aware.ie (click on the books link).
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