Depression in Childhood and Adolescence

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

This topic covers depression in children and teens. For information about adult depression, see the topic Depression. For information about childhood or teen bipolar disorder (depression with episodes of mania), see the topic Bipolar Disorder in Childhood and Adolescence.

What is depression in childhood and adolescence?

Depression is a mood disorder that causes a child or teen to feel sad or irritable for a long period of time. A young person who is depressed may not enjoy school, play, or friends and may have low energy and other symptoms. As with an adult, symptoms of depression range from mild to severe and vary from person to person. Depression can last for a long time and may come in cycles of feeling down and feeling normal. Chronic (ongoing) mild depression, called dysthymia, occurs when a child feels a little down most of the time for a year or more. Both severe and mild forms of depression can be effectively treated.

It was once thought that only adults developed depression and that children and teens could not. We now know that even a young child can develop serious depression that needs treatment to improve. However, symptoms of depression in children and teens can be difficult to recognize. They range from boredom to stomach pain and may seem to be symptoms of something else. Many children and teens who are depressed do not get adequate treatment because their symptoms are not identified. Mood swings and other emotional changes caused by depression may be overlooked as unimportant or as a normal part of growing up.

Children and teens with depression frequently have other conditions such as anxiety disorders, behavior disorders like attention deficit hyperactivity disorder (ADHD), eating disorders, learning disorders, or serious behavior problems (conduct disorder). These conditions may occur before a child is diagnosed with depression.

At one time it was a common belief that depression is "all in the mind" and that a depressed person should be able to snap out of it. We now know that depression is an illness that requires treatment—not a character flaw or weakness. Childhood and teen years can be especially difficult for children with depression and their family members, especially if it is not treated. Untreated major depression can last for a year and sometimes longer.¹ Prolonged or severe depression can lead to problems making and keeping friends, difficulty in school, substance abuse, suicidal behavior, and other problems that may carry into adulthood. If you think your child may be depressed, seek help from a health professional.

What causes depression?

Depression can be triggered by stressful life events, such as a loss or a move, or by certain drugs or medications. Depression may also be genetic (inherited). Children with a family history of depression are much more likely to become depressed, especially if they have a parent who is currently depressed.¹ Although the causes of depression are not entirely understood, we know it is linked to an imbalance of brain chemicals called neurotransmitters. This chemical imbalance can be caused by medications, illnesses, or stress.

What are the symptoms?

Symptoms of depression are different from the normal ups and downs of life that may cause your child to feel a little "blue" from time to time. Symptoms often go on for a long time and may change as depression gets worse. Often the first signs of depression are irritability, sadness, or boredom. Children or teens with depression may also have behavior problems or problems in school.²

The symptoms of depression are often subtle at first. It can be hard to recognize that symptoms may be connected and that your child might have depression. The main symptoms used to diagnose depression in children of any age are long-term irritability, sadness, and a loss of pleasure in activities once enjoyed. Other symptoms include:³

• Changes in appetite that may lead to problems maintaining a normal weight.
• Problems with sleeping or sleeping too much.
• Feeling hopeless, worthless, or guilty.
• Difficulty concentrating, thinking, or making decisions.
• Recurring thoughts of death or suicide.

Young children commonly have different symptoms than older children or teens.³

Very young children may lack energy and become withdrawn, show little emotion or seem to feel hopeless, and have problems sleeping.

Elementary school children may feel constantly tired, irritable, sad, or guilty and complain of pain such as headaches or stomach pain. They may lose interest in friends and activities that they once enjoyed. In some cases, children with severe depression may lose touch with reality. They may hallucinate (see or hear things that don't exist) or have delusions (false beliefs).

Teens may sleep a lot or move or speak more slowly than usual. Teens with severe depression may also hallucinate or have delusions.

Symptoms of depression are different than a temporary response to a loss, disappointment, or tragic event (bereavement or grief). However, a stressful or traumatic situation can sometimes lead to depression (if symptoms are severe or long-lasting).

Deciding whether symptoms of depression in your child are normal preteen or teen moodiness or may be caused by depression or another disorder can be difficult and stressful. However, once a young person is diagnosed with depression by a health professional, treatment is usually successful.

If you think you may have depression, take a short quiz to evaluate your symptoms:

Are you depressed?

How is it treated?

Treatment for childhood and teen depression usually includes professional counseling, medications, and family education. A combination of these treatments may be needed.⁴

If your child or teen has mild or moderate depression, he or she may be diagnosed and treated by your family health professional and a therapist or psychologist. A doctor who specializes in the diagnosis and treatment of mental health problems (psychiatrist) may be helpful for severe depression or other mental health problems that occur with depression.

Sometimes a stay in the hospital may be needed if the child or teen has suicidal thoughts and is likely to act on them or has other health conditions, such as a long-term disease, an eating disorder, or another mood disorder.

What problems are linked to depression in young people?

Problems linked to depression in a child or teen include:

• A lifetime chance of getting depression again and an increased chance of having severe depression as an adult.
• Anxiety disorders, such as general anxiety disorder, separation anxiety, or a social anxiety disorder. A child or teen with an anxiety disorder has intense fears or worries that interfere with normal life, often before he or she becomes depressed.
• Disruptive behavior disorders, such as attention deficit hyperactivity disorder (ADHD) or conduct disorder. A young person with ADHD may have difficulty paying attention, may be overly energetic, and may act without thinking. Conduct disorder is a long-term disorder during childhood or adolescence that involves defiant behavior, such as breaking social rules or hurting other people. Conduct disorder often occurs with ADHD.
• Substance abuse, a pattern of alcohol or drug use that causes problems.
• Suicidal behavior, such as a preoccupation with death, withdrawal from friends and family, or reckless behavior. Suicide is the third leading cause of death for teens and young adults.⁵ The risk of suicide increases when depression is not properly treated. If you think your child may be depressed, let your health professional know and have your child evaluated right away.

How common is depression in childhood and adolescence?

Major depression has been estimated at 1% to 3% in young children and between 3% and 9% in adolescents. These estimates are higher when young people with minor depression are included.²

Before puberty, depression occurs equally in boys and girls. However, between the ages of 15 and 18, girls are twice as likely to experience depression as boys.⁶ Depression lasts an average of 8 months in children and teens, but sometimes it lasts much longer. Even with treatment, over half of those children and teens with depression have another depressive episode within 5 years.⁴

Frequently Asked Questions

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	Should my child take medications to treat depression?

Depression is thought to be caused by an imbalance of chemicals called neurotransmitters that send messages between nerve cells in your brain. Some of these chemicals, such as serotonin, help regulate mood. If these mood-influencing chemicals get out of balance, depression or other mood disorders can result. Experts have not yet identified why neurotransmitters become imbalanced. They believe a change can occur as a response to stress or illness, but a change may also occur with no obvious trigger.

There are several factors known to increase the chances that a young person may become depressed.

• Depression runs in families. Children and teens who have a parent with depression are 3 times more likely to develop depression than children with parents who are not depressed.¹ Experts believe that both inherited traits (genetics) as well as living with a parent who is depressed can cause depression.
• Depression in children and teens may be linked to stress, social problems, and unresolved family conflict. It can also be linked to traumatic events, such as violence, abuse, or neglect.
• Children or teens who have long-term or serious medical conditions, learning problems, or behavior problems are more likely to develop depression.
• Some medicines can trigger depression, such as steroids or narcotics for pain relief. Once the medicine is stopped, symptoms usually disappear.

Depression in a child or teen may occur suddenly or develop gradually. Your child may seem more irritable than sad or may feel bored or hopeless. It is common for others to notice that a depressed child's body movements are slow, restless, or agitated. Your child may be self-critical or feel that others are unfairly critical of him or her.

The symptoms of depression are often subtle at first. It can be hard to recognize that symptoms may be connected and that your child might have depression.

Children who are depressed may have the following symptoms:^{7, 3}

• Irritability
• Temper tantrums
• Unexplained aches and pains, such as headaches or stomach pain
• Difficulty thinking and making decisions
• Problems with sleeping or sleeping too much
• Changes in eating habits that lead to weight gain or loss or not making expected weight gains
• Low self-esteem
• Feelings of guilt and hopelessness
• Constant tiredness or lack of energy
• Social withdrawal, such as lack of interest in friends
• Thinking about death or feeling suicidal

Untreated depression can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

Many children who are depressed have symptoms of anxiety, such as worrying too much or fearing separation from a parent. Sometimes these symptoms appear before depression is diagnosed.

Other less common symptoms may occur in severely depressed children, such as hearing voices that aren't there (hallucinations) or having false but firmly held beliefs (delusions). Hallucinations are more common in young children, while delusions are more common in teens.⁸

Telling the difference between normal moodiness and symptoms of depression can be difficult. Occasional feelings of sadness or irritability are normal. They allow the child to process grief or cope with the challenges of life. For example, grieving (bereavement) is a normal response to loss, such as the death of a family member or even the death a pet, loss of a friendship, or parents' divorce. After a severe loss, a child may remain sad for a longer period of time. However, when these emotions do not go away or begin to interfere with the young person's life, the child may develop signs of a mood disorder such as depression or dysthymic disorder (long-term, mild depression), which requires treatment.

About 15% of children or teens who are diagnosed with depression develop bipolar disorder.⁹ Children or teens with bipolar disorder have extreme mood swings between depression and bouts of mania (very high energy, agitation, or irritability). Depression can have symptoms that are similar to those caused by other conditions.

It can be difficult to distinguish bipolar disorder from depression. It is common for children with bipolar disorder to first be diagnosed with only depression and later to be diagnosed with bipolar disorder after a first manic episode. Although depression is part of the condition, bipolar disorder requires different treatment than depression alone. Like depression, bipolar disorder runs in families, so be sure to tell your health professional if your child has a family history of bipolar disorder. (For more information on bipolar disorder, see the topic Bipolar Disorder in Childhood and Adolescence.)

Depression in a child or teen may first appear as irritability, sadness, or sudden, unexplained crying. He or she may lose interest in activities once enjoyed or feel unloved and hopeless. He or she may have problems in school and become withdrawn or defiant.

Often a child who is depressed will have other disorders along with depression, such as an anxiety disorder, a behavior disorder like attention deficit hyperactivity disorder (ADHD), an eating disorder, or a learning disorder. These problems may occur before a young person becomes depressed. Some children with depression develop serious behavior problems (conduct disorder), usually after becoming depressed. If your child develops one of these disorders, it may require treatment along with depression.

A child or teen with depression is much more likely to use drugs, alcohol, or cigarettes than a young person who is not depressed. Approximately 30% of teens will develop alcohol or drug use problems along with depression.¹⁰ This can make depression more difficult to treat, can increase the length of time before treatment is successful, and increases the risk of suicide. Early diagnosis and treatment of depression and good communication with your child can help prevent substance abuse. For more information about substance abuse in young people, see the topic Teen Alcohol and Drug Abuse.

Children and teens with depression are also at a higher risk for developing problems such as:^{4, 11}

• Poor school or job performance.
• Problems in relationships with peers and family members.
• Early pregnancy.
• Physical illness.

For severe depression, your child may need to be hospitalized, especially if he or she is out of touch with reality (psychotic) or having thoughts of suicide.

A depressive episode lasts an average of 8 months.⁶ Even with successful treatment, as many as 70% of children with depression will have another episode within 5 years.¹² During treatment for depression, make sure your child takes medications and attends counseling appointments as directed, even if he or she feels better. A common cause of relapse is stopping treatment too soon.

To prevent another episode of depression, learn to recognize early warning signs of depression, and seek diagnosis and treatment right away if symptoms develop. A balanced diet, exercise, and a good social support system may also help prevent depression.

Suicide and depression

Untreated depression can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship. Teens with depression are at particularly high risk for suicide and suicide attempts. In the United States, approximately 2,000 teens commit suicide each year.⁵ While teen girls attempt suicide almost twice as often as teen boys, boys are more likely to succeed because girls usually use less lethal means and survive the attempt. Suicide attempts in children younger than age 12 are uncommon.

A young person is at increased risk for suicide attempts if he or she has:¹³

• Current suicidal thoughts.
• Other mental health or disruptive disorders, such as conduct disorder.⁵
• Impulsive or aggressive behaviors.
• Feelings of hopelessness.
• A history of past suicide attempts.
• A family history of suicidal behavior or mood disorders.
• A history of being exposed to family violence or abuse.
• Access to firearms or other potentially lethal means.

You should carefully watch for signs of suicidal behavior if your child has recently:

• Broken up with a girlfriend or boyfriend.
• Had disciplinary troubles in school or with the law.
• Had problems with poor grades or difficulty learning.
• Had family problems.
• Had substance abuse problems.
• Started, stopped, or changed doses of an antidepressant medication.

If your child is suicidal, call 911 or other emergency services immediately.

Several factors increase a young person's chance of developing depression. These include:^{4, 1, 7}

• Having a parent or immediate family member who is depressed. This is the most important risk factor for depression. Children or teens who have a parent with depression are 3 times more likely to develop depression.
• Having been depressed before, especially if depression first occurred at an early age.
• Having a long-term medical condition such as diabetes or epilepsy.
• Having another mental disorder, such as conduct disorder or an anxiety disorder.
• Having a family member or close friend die.
• Being physically or sexually abused.
• Having problems with alcohol or drug use.

Other risk factors for depression include:

• Being a girl in early puberty. Until puberty, boys and girls have an equal risk of developing depression. After puberty and as adults, females are twice as likely as males to become depressed.
• Being exposed to family conflict.
• Not having good social relationships with peers.
• Being a bully or a victim of bullying.¹⁴

Call 911 or other emergency services immediately if:

• Your child makes threats or attempts to harm himself or herself or another person, or shows other warning signs of suicide.
• Your child hears voices (has auditory hallucinations).
• You are a young person and you feel you cannot stop from harming yourself or someone else.

Watchful Waiting

Taking a wait-and-see approach, called watchful waiting, may be appropriate if your child has feelings of grief, sadness, or melancholy.

However, you should contact a health professional right away if symptoms of depression last more than 2 weeks or if your child's symptoms are interfering with his or her normal daily functioning.

Untreated depression can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

Who To See

Treatment for depression may involve professional counseling, medication, family education, or a combination of these. It is important that your child establish a long-term and comfortable relationship with the care providers for the treatment of depression.

Your child may be diagnosed and treated by more than one health professional, including a:

• Pediatrician.
• Psychiatrist.
• Psychologist.
• Family medicine physician.
• Physician assistant.
• Nurse practitioner.

Professional counseling (or psychotherapy) for depression can be provided by a:

• Psychiatrist.
• Psychologist.
• Social worker.
• Licensed mental health counselor.
• Psychiatric nurse.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Your doctor or another health professional will evaluate and diagnose depression in your child by asking questions about your child's medical history and conducting tests to determine if symptoms are caused by something other than depression. Your child may be given a physical exam or blood tests to rule out conditions such as hypothyroidism or anemia. Your child may be asked to complete a mental health assessment, which tests his or her ability to think, reason, and remember.

You may be asked to help complete a pediatric symptom checklist, a brief screening questionnaire that helps to diagnose depression or other psychological problems in children. Also, your child may be asked to take a short written or verbal test for depression.

Sometimes a more thorough evaluation may be needed to fully assess your child's depression. Interviews may be conducted with the parents or with other people who know the young person well. Specific information may be obtained from the child's teachers or from social service workers.

Treatment for depression in young people is similar to treatment for depression in adults and includes counseling and medications. Although antidepressant medications can be effective in treating depression, the safety and long-term effects of these medications in children are not yet fully understood. However, for many young people with depression, experts believe the benefits of the medications outweigh the risks.

Less than one-third of children or teens with depression receive treatment.³ This may be due, in part, to the old belief that young people do not get depression or that feeling depressed is normal for their age. Also, teens often do not seek help for depression, because they may think feeling bad is normal, they may blame something else (or themselves) for their symptoms, or they may not know where to go for help. Tell your child to ask for help if he or she feels bad, and let your child know who to go to for help with depression or other problems.

Initial treatment

The type of treatment your child requires depends on whether he or she is having a first episode, the severity of the depression, and issues related to the cause of the depression, such as family conflict or academic problems.⁴ If your child is suicidal or is severely depressed and is out of touch with reality (psychotic) or unable to function, a stay in the hospital may be needed.

Treatment of depression in children and teens generally includes professional counseling, medication, and education of family members.

Professional counseling for depression may include:

• Cognitive-behavioral therapy, which focuses on changing certain thinking and behavior patterns.
• Interpersonal therapy, which focuses on social and personal relationships and related problems.
• Problem-solving therapy, a type of cognitive therapy that helps you find practical solutions to problems.
• Family therapy, which can help educate and comfort the whole family.
• Play therapy, for very young children.

Medications used to treat childhood depression include:

• Selective serotonin reuptake inhibitors (called SSRIs), such as fluoxetine (Prozac). SSRIs are the medications most often used for childhood or teen depression. Fluoxetine is currently the only SSRI approved by the U.S. Food and Drug Administration (FDA) for use in children, although other SSRIs are sometimes used.
• Atypical antidepressant medications, such as venlafaxine (Effexor) or bupropion (for example, Wellbutrin) In some cases, these may be used to treat childhood or teen depression.
• Monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil). MAOIs are rarely given due to potentially serious side effects and dietary restrictions.
• Tricyclic antidepressants such as amitriptyline (Elavil, for example). Tricyclic antidepressants have been used in the past for childhood depression, but recent studies have found limited evidence that these medications are effective.¹⁵ Tricyclics also carry the risk of overdose and other serious consequences, such as heart problems.

Should my child take medications to treat depression?

The FDA has approved the use of fluoxetine (Prozac, for example) for the treatment of depression in children and teens. However, other medications that are used to treat adult depression may also be tried to treat childhood depression, even though these medications have not been officially approved for children by the FDA.

The FDA has issued advisories stating that people who are taking antidepressants for depression, along with their family members and their health professionals, should watch for warning signs of suicide.

Education of family members can be provided by a health professional either informally or in family therapy. Some of the most important things family members can learn include:

• Knowing how to make sure a child is following a treatment plan, such as taking medication correctly and going to counseling appointments.
• Learning ways to reduce stress caused by living with someone who has depression.
• Knowing the signs of a relapse and what to do to prevent depression from recurring.
• Knowing the signs of suicidal behavior, how to evaluate their seriousness, and how to respond.
• Learning how to identify signs of a manic episode, which is a bout of extremely high energy or irritability that is a sign of bipolar disorder.
• Seeking treatment if you are a parent with depression.

Home treatment is an important part of treating depression. It includes:

• Getting regular exercise, such as vigorous playing, swimming, or walking, to help reduce stress.
• Eating a healthy, balanced diet.
• Getting enough sleep regularly. (Children and teenagers need more sleep than adults.)
• Avoiding the use of alcohol, tobacco, or drugs.

Ongoing treatment

Ongoing treatment depends on how severe your child's symptoms are and whether the symptoms are interfering with his or her daily activities and quality of life. Treatment includes professional counseling and may include long-term treatment with medications.

Some children and teens do not respond to the first medication given and may need to try several different medications to find relief from their symptoms. Both medications and professional counseling may be the most effective treatment, especially for children with long-term (chronic) depression that has lasted over a year.⁶

An important part of ongoing treatment is making sure your child takes medications as prescribed. Often people who feel better after taking an antidepressant for a period of time may feel like they are "cured" and no longer need treatment. However, when medication is stopped, symptoms usually return, so it is important that your child follows the treatment plan.

Your child will also need to keep counseling appointments and continue with lifestyle changes, such as eating healthy foods and getting regular exercise.

If your child has an additional illness along with depression, he or she will need to continue receiving treatment for the other illness. Tell all health professionals what medications your child is taking and the treatment he or she is receiving.

Treatment if the condition gets worse

If your child's condition gets worse during treatment for depression (which includes counseling, medications, and lifestyle changes), additional treatment may be needed. Steps include:

• Making sure your child is taking medications as prescribed and is following other treatment recommendations, such as going to counseling appointments.
• Finding out whether ongoing symptoms are caused by another disorder (such as attention deficit hyperactivity disorder (ADHD), anxiety disorder or substance abuse) and treating the other condition if needed.
• Identifying and reducing stresses that may be making symptoms worse.
• Changing the dose or type of medication your child is taking.
• Making sure your child continues with home treatments, such as eating a balanced diet and getting regular exercise.

A brief hospital stay may be needed, especially if your child is showing any warning signs of suicide (such as aggressive or hostile behavior, excessive thoughts about death, or detachment from reality) or is so depressed that he or she becomes out of touch with reality (psychotic) or has hallucinations or delusions. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

If your child is depressed, consider removing all guns and potentially fatal medications from your home, especially if your child has shown any warning signs of suicide. Although overdosing on medication is the most common way adolescents attempt suicide, your child is at higher risk for completing a suicide if you have a gun in your home, particularly if it is easily accessible or you store it loaded.⁶

You may also want to consider having your child agree to a safety plan in case of suicidal feelings, which is called a verbal or written no-suicide contract. The child agrees not to try to inflict self-harm and to tell an adult if he or she is feeling suicidal. Evidence about whether no-suicide contracts are effective in preventing suicidal behavior or completed suicide is still being evaluated. It isn't yet clear whether these agreements help or how much, but many health professionals feel that they may be useful. See an example of a no-suicide contract (What is a PDF document?).

For older children with severe depression, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. This is thought to relieve depression by altering brain chemicals known as neurotransmitters.

What To Think About

Although experts believe that, for many children with depression, the benefits of medication outweigh the risks, research on antidepressant medication in children is limited. The long-term effects and safety of medications used to treat depression in children and teens are still unknown. Recent U.S. Food and Drug Administration (FDA) advisories warn about the possibility of increased risk for suicide in people taking antidepressant medications.

Family involvement in the treatment for depression can be very important, especially for children and teens. Sometimes parents of children and teens with depression also may be or may become depressed and need treatment too. If a parent's depression goes untreated, it may interfere with the recovery of the child.

The sooner treatment begins for depression, the more rapidly your child is likely to recover. Waiting to seek treatment for depression may result in a longer and more difficult recovery.

It may take several weeks for a medication to become fully effective, although symptoms may begin to improve sooner.¹⁰ It can be difficult to wait during this time to see improvement in symptoms. Your child may need to try several different medications before finding a medication that works.

It is common for children and teens to have another episode of depression (relapse) within 2 to 5 years of the first episode.

It is difficult to prevent a first episode of depression, but it may be possible to prevent or reduce the severity of future episodes of depression (relapses).

• There is some evidence that if a child receives cognitive-behavioral therapy (CBT) in a group setting, it can help prevent or delay the onset of depression in a child or teen whose parent has depression (which puts the child at greater risk for becoming depressed).¹⁶
• Your child must take medications as prescribed, keep counseling appointments, eat a balanced diet, and get regular exercise.
• Make sure your child has a good social support system, both at home and through teachers, other family members, and friends who can provide encouragement and understanding.
• Learn to recognize early symptoms of depression and seek immediate diagnosis and treatment if they occur.
• Some schools provide educational materials and group therapy opportunities to those at high risk of developing depression, such as those who have family conflict or problems with peers.¹³

You should do everything possible to provide a family environment for your child that is supportive and understanding. Love, understanding, and regular communication are some of the most important things you can provide to help your child cope with depression.

In addition to having a positive home life, staying in professional counseling, and taking medications as prescribed, good lifestyle habits can help reduce your child's symptoms of depression. Encourage your child to:

• Get regular exercise, such as swimming, walking, or playing vigorously every day.
• Avoid alcohol and illegal drugs, nonprescription medications, herbal therapies, and medications that have not been prescribed (because they may interfere with the medications used to treat depression).
• Get enough sleep. If your child has problems sleeping, he or she might try:
  • Going to bed at the same time every night.
  • Keeping the bedroom dark and quiet.
  • Not exercising after 5:00 p.m.
• Eat a balanced diet. If your child lacks an appetite, try to get him or her to eat small snacks rather than large meals.
• Be hopeful about feeling better. Positive thinking is very important in recovering from depression. It is difficult to be hopeful when you feel depressed, but remind your child that improvement occurs gradually and takes time.

If you notice any warning signs of suicide (such as aggressive or hostile behavior, excessive thoughts about death, or detachment from reality) seek professional help immediately by calling either your child's doctor, a professional counselor, or a local mental health or emergency services. Call 911 if you feel your child is in immediate danger.

Medications used to treat depression in children and teens are currently being researched for safety and long-term effects. You may have heard about concerns regarding a possible connection between antidepressant medications and suicidal behavior. The U.S. Food and Drug Administration (FDA) has issued advisories about this issue. Especially during the first few weeks of treatment with an antidepressant, there is a possible increase in suicidal feelings or behavior. A child beginning antidepressant treatment should be monitored closely. However, children with untreated depression are also at an increased risk for suicide, so it is important to carefully weigh all of the risks and benefits of antidepressant medication.

Medication Choices

Medication choices include:

• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, for example). Fluoxetine is currently the only SSRI approved for treating depression in children and teens. However, other SSRIs such as citalopram (Celexa) or sertraline (Zoloft) may be effective and are sometimes prescribed.
• Atypical antidepressant medications, such as bupropion (Wellbutrin, for example) or venlafaxine (Effexor).
• Monoamine oxidase inhibitors (MAOIs), such as tranylcypromine (Parnate) or phenelzine (Nardil).
• Tricyclic antidepressants such as amitriptyline (such as Elavil) or desipramine (such as Norpramin). Tricyclic antidepressants have been used in the past for childhood depression, but recent studies have found limited evidence that these medications are effective.¹⁵ Tricyclics also carry the risk of overdose and other serious consequences, such as heart problems.

What To Think About

While antidepressant medications such as fluoxetine (Prozac, for example) can be effective in treating depression, it usually takes at least several weeks before the medication begins to work.

SSRIs may also be effective in treating other conditions such as anxiety.

Your child may have to try several medications before the most effective treatment is discovered. Once the right medication is found, your child may need to continue taking the medication for several months or longer after the symptoms of depression have subsided to prevent depression from occurring again.

Some children who are first diagnosed with depression are later diagnosed with bipolar disorder, which has symptoms that cycle from depression to mania (very high energy, often with euphoria, agitation, irritability, risk-taking behavior, or impulsiveness). If your child or teen has bipolar disorder, a first episode of mania can happen spontaneously, but it can also be triggered by certain medications such as stimulants or antidepressants. That is why it is very important to tell your child's health professional about any family history of bipolar disorder and to monitor your child closely for signs of manic behavior. For more information about bipolar disorder in young people, see the topic Bipolar Disorder in Childhood and Adolescence.

Should my child take medications to treat depression?

FDA Advisories. The US Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines, but to watch for warning signs of suicide in those using them. This is especially important at the beginning of treatment or when doses are changed.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.

While medications can be an effective treatment for children with depression, the FDA has asked drug companies to include extensive packaging information warning about the danger of suicidal thoughts or actions during antidepressant use. The FDA encourages anyone considering the use of an antidepressant in a child or teen to balance the increased risk with the need to use the medication. If your child is taking an antidepressant, do not stop its use suddenly. Talk to your health professional about any concerns you may have, and watch your child closely for any warning signs of suicide.

There is no surgical treatment for depression at this time.

Professional counseling is an important part of treatment for depression. Lifestyle changes, such as getting regular exercise and enough sleep, may also help your child recover more quickly and improve his or her quality of life. Family therapy may be helpful for your entire family while you are dealing with depression in your child.

Having a child with depression can be challenging and requires understanding and patience. You should learn as much as you can about childhood depression and what you and other family members can do to help treat it. Family therapy can be an effective way to learn the best ways to help.

Electroconvulsive therapy (ECT) may be an effective treatment for a teen or older child who is severely depressed or does not respond to other treatment, although this treatment is rarely used for children and teens. Even though it is an effective treatment for adults with major depression, there are currently no long-term studies on the safety of using ECT for children and teens or adults.^{17, 18}

Other Treatment Choices

Professional counseling is an important part of the treatment for depression. Types of counseling most often used to treat depression in children and teens are:

• Cognitive-behavioral therapy, which helps reduce negative patterns of thinking and encourages positive behaviors.
• Interpersonal therapy, which focuses on the child's relationships with others.
• Problem-solving therapy, which helps the child deal with current problems.
• Family therapy, which provides a place for the whole family to express fears and concerns and develop new ways of getting along.
• Play therapy, which is used with young children or children with developmental delays to help them cope with fears and anxieties.¹⁹ However, there is no proof that this type of treatment reduces symptoms of depression.

Electroconvulsive therapy (ECT), while seldom used on children, may be helpful for those who either have not responded to other treatments or whose depression is severe.

Complementary medications

Complementary medications such as St. John's wort have been used to treat depression in adults, but their effectiveness in children and teens has not been adequately studied. There is no evidence that these therapies are safe for use by children or teens.²⁰ Complementary medications can also interfere with other medications, such as antidepressants.

What To Think About

Some symptoms of depression in children and teens may remain, even with medication and other treatment. Depression in young people can be an ongoing problem and may need long-term treatment with professional counseling, medications, education about the disorder, or a combination of these. Early treatment of depression may bring about the best results for your child.

Online Resources

Organizations

• Anorexia Nervosa
• Anxiety
• Attention Deficit Hyperactivity Disorder (ADHD)
• Bipolar Disorder
• Bulimia Nervosa
• Bullying
• Depression
• Growth and Development, Ages 11 to 14 Years
• Growth and Development, Ages 15 to 18 Years
• Growth and Development, Ages 6 to 10 Years
• Obsessive-Compulsive Disorder (OCD)
• Post-Traumatic Stress Disorder
• Schizophrenia
• Seasonal Affective Disorder (SAD)
• Teen Alcohol and Drug Abuse

Citations

1. Dahl RE, Brent D (2003). Affective disorders and suicide. In CD Rudolph et al., eds., Rudolph's Pediatrics, 21st ed., pp. 501–503. New York: McGraw–Hill.

2. Dulcan MK, et al. (2003). Mood disorders section of Adult disorders that may begin in childhood or adolescence. Concise Guide to Child and Adolescent Psychiatry, 3rd ed., pp. 129–177. Washington, DC: American Psychiatric Publishing.

3. American Academy of Pediatrics (1996). Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care Child and Adolescent Version, pp. 153–160. Elk Grove Village, IL: American Academy of Pediatrics.

4. American Academy of Child and Adolescent Psychiatry (1998). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 37(10): 63S–83S.

5. American Academy of Child and Adolescent Psychiatry (2001). Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 40(Suppl 7): 24S–51S.

6. Brent DA, Birmaher B (2002). Adolescent depression. New England Journal of Medicine, 347(9): 667–671.

7. Depression and suicide in children and adolescents (2000). Mental Health: A Report of the Surgeon General. Available online: http://www.mentalhealth.org/features/surgeongeneralreport/chapter3/sec5.asp.

8. Boris NW, et al. (2004). Mood disorders. In RE Behrman et al., eds., Nelson Textbook of Pediatrics, 17th ed., pp. 84–85. Philadelphia: Saunders.

9. American Psychiatric Association (2000). Bipolar disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 382–397. Washington, DC: American Psychiatric Association.

10. Renaud J, et al. (1999). A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents. Drug Safety, 20(1): 59–75.

11. Rao U, et al. (1999). Factors associated with the development of substance use disorders in depressed adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38(9): 1109–1117.

12. Hazell P (2002). Depression in children and adolescents. Clinical Evidence (7): 307–313.

13. Garber J, McCauley E (2002). Prevention of depression and suicide in children and adolescents. In M Lewis, ed., Child and Adolescent Psychiatry, 3rd ed., pp. 805–821. Philadelphia: Lippincott Williams and Wilkins.

14. Saluja G, et al. (2004). Prevalence of and risk factors for depressive symptoms among young adolescents. Archives of Pediatric and Adolescent Medicine, 158(8): 760–765.

15. Hazell P, et al. (2002). Tricyclic drugs for depression in childhood and adolescence. Cochrane Database of Systematic Reviews (3). Oxford: Update Software.

16. Clarke GN, et al. (2001). A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Archives of General Psychiatry, 58(12): 1127–1134.

17. Butler R, et al. (2005). Depressive disorders. Clinical Evidence (13): 1238–1276.

18. Hazell P (2004). Depression in children and adolescents. Clinical Evidence (11): 391–402.

19. Weller EB, et al. (2002). Depressive disorders in children and adolescents. In M Lewis, ed., Child and Adolescent Psychiatry, 3rd ed., pp. 767–781. Philadelphia: Lippincott Williams and Wilkins.

20. Committee on Children With Disabilities, American Academy of Pediatrics (2001). Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability. Pediatrics, 107(3): 598–601.

Other Works Consulted

• American Psychiatric Association (2000). Seasonal pattern section of Mood disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 425–427. Washington, DC: American Psychiatric Association.

• Birmaher B, Brent DA, et al. (2000). Clinical outcomes after short-term psychotherapy for adolescents with major depressive disorder. Archives of General Psychiatry, 57(1): 29–36.

• Brent DA, et al. (1997). A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry, 54(9): 877–885.

• Brent DA, et al. (1998). Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry, 37(9):906–914.

• Klein DN, et al. (2001). A family study of major depressive disorder in a community sample of adolescents. Archives of General Psychiatry, 58(1): 13–20.

• March JS, et al. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) Randomized Controlled Trial. JAMA, 292(7): 807—820

• Martin A, et al. (2000). Pharmacotherapy of early onset depression. Child and Adolescent Psychiatric Clinics of North America, 9(1): 135–157.

• Taieb O, et al. (2000). Adolescents' experiences with ECT. Journal of the American Academy of Child and Adolescent Psychiatry, 39(943): 943–944.

Author:	Stuart J. Bryson	Last Updated May 28, 2005
Medical Review:	Michael J. Sexton, MD - Pediatrics David A. Brent, MD - Child and Adolescent Psychiatry Lisa S. Weinstock, MD - Psychiatry
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