Childhood and adolescent depression is often recurrent and continues episodically into adulthood. It can occur with comorbid psychiatric disorders, increased risk of suicide, substance abuse and behavioural problems. Depression affects the whole of a person's life, impairing occupational, social, emotional and physical health and carrying considerable stigma.
- The prevalence of childhood depression has been estimated to be 1% in prepubertal children and about 3% in postpubertal young people.
- Depression is experienced by twice as many adolescent females as it is by males.
- The prevalence appears to be increasing and affecting younger children, although this may in part be due to greater awareness and improved diagnosis.
- Children and adolescents with depression frequently have psychosocial, educational and family difficulties.
- Family discord.
- Physical, sexual or emotional abuse.
- History of parental depression.
- Ethnic and cultural factors.
- Refugee status.
- Living in institutional settings.
The diagnosis is often missed and there is limited evidence that primary screening tools may accurately identify depressed adolescents.
- Often with somatic symptoms and may also have features of anxiety.
- Sometimes only presents as poor functioning at school, socially, or at home.
- It may even masquerade as bad behaviour, particularly in boys.
- Mood is characteristically much more variable and less pervasive than in adults, and rapid mood swings often occur.
- The fact that children are able to enjoy some aspects of their lives shouldn't preclude the diagnosis of depression.
- Features as seen in adults:
- Low mood.
- Loss of interest.
- Socially withdrawn.
- Poor self-esteem.
- Psychomotor impairment.
- Lack of enjoyment in anything.
- Features common in childhood:
- Running away from home.
- Separation anxiety and possibly school refusal.
- Complaints of boredom.
- Poor school performance.
- Antisocial behaviour.
- Insomnia (often initial and middle rather than early morning wakening) or hypersomnia.
- Eating increased or decreased, particularly if associated with weight change.
- Young primary school children may present with sadness and helplessness; slightly older children with feelings of being unloved and unfairly treated. Guilt and despair may be more prominent in teenagers.
- Consider the possibility of concealed contributory factors - eg, past child abuse, bullying.
- Parents may not always be aware of depression in their children.
- Assessment is frequently difficult and many questions may only be answered by silence or a shrug.
- Adolescents with conduct disorders can be manipulative and extremely difficult to assess - an urgent second opinion is frequently required.
- Always ask about suicide ideation and thoughts of self-harm:
- Note any past attempts, as about 15-20% make further attempts (males, those with conduct disorder, excessive alcohol use, hopelessness and those in local authority care are at increased risk).
- Self-harm can be regarded as a form of communication, not always 'picked up' and sometimes difficult to decipher the teenager's exact intentions. Deliberate self-harm is common in adolescents, especially females.
- Refer urgently if the risk is considered significant.
Particular attention should be paid, when dealing with depression in young people, to:
- The young person's consent (including Gillick competence).
- Parental consent.
- Child protection.
- The use of the Mental Health Act in young people.
- The use of the Mental Capacity Act in young people.
- The use of the Children Act.
- It is common for management to be based in secondary care with support from primary care. This reflects frequent difficulties in diagnosis, variable access to psychological interventions within primary care and current controversy about the efficacy and safety of antidepressant medication in those aged under 18 years.
- However, primary care services (including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services) may be appropriate in cases with factors such as:
- Exposure to a single undesirable event in the absence of other risk factors for depression.
- Exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self-harm.
- Exposure to a recent undesirable life event where one or more family members (parents or children) have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child/young person.
- Mild depression without comorbidity.
- Refer to Child and Adolescent Mental Health Services (CAMHS), including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists in cases with the following factors:
- Depression where one or more family members (parents or children) have multiple-risk histories for depression.
- Mild depression in those who have not responded to interventions in primary care after 2-3 months.
- Moderate or severe depression (including psychotic depression).
- Signs of a recurrence of depression in those who have recovered from previous moderate or severe depression.
- Unexplained self-neglect of at least one month's duration that could be harmful to the child/young person's physical health.
- Active suicidal ideas or plans. High recurrent risk of acts of self-harm or suicide.
- Young person or parent(s)/carer(s) request referral.
- Social interventions:
- Addressing any sources of distress (eg, bullying) and removing opportunities for self-harm (eg, paracetamol at home).
- Psychological interventions:
- Computerised (digital) cognitive behavioural therapy (cCBT) should be offered as a first-line treatment to children and young people aged 5 to 18 years with mild depression continuing after two weeks of watchful waiting. Group CBT, group non-directive supportive therapy, group interpersonal psychotherapy and group mindfulness should also be considered as first-line options.
- If the above are not suitable or would not meet the child's needs, attachment-based family therapy or individual CBT should be considered.
- Children and young people aged 5-11 years with moderate-to-severe depression should be offered, as a first-line treatment, a specific psychological therapy (individual cCBT, family therapy, psychodynamic psychotherapy or family-based interpersonal therapy(IPT)).
- Children and young people aged 12-18 years should be offered individual CBT for at least three months or, if this would not meet their needs or would be unsuitable, IPT for adolescents, attachment-based or systemic family therapy, brief psychosocial intervention or psychodynamic psychotherapy.
- Counsellors, sympathetic teachers and youth workers may be a resource to help children and young people.
- The evidence surrounding combination therapy with psychological interventions and antidepressants is limited. A Cochrane review showed there is limited evidence that combination therapy with psychological interventions and antidepressants is more effective than just antidepressants.
- Patient and carer preferences and values, as well as the young person's maturity and personal circumstances should, if appropiate, be taken into account in determining the choice of psychological therapy.
- The overall evidence may be limited but the National Institute for Health and Care Excellence (NICE) recommends that antidepressant medication should only be used in combination with concurrent psychological therapy.
- Fluoxetine should be prescribed, as this is the only antidepressant for which trials show that the benefits outweigh the risks.
- In 2008, after a meta-analysis of data on antidepressants including selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine (noradrenaline) reuptake inhibitors (SNRIs), the Medicines and Healthcare products Regulatory Agency (MHRA) has stated that the risk of suicidal acts and behaviour is increased with the use of SSRIs or SNRIs in young people aged up to 25 years.
- Those at highest risk are children, adolescents and young adults. One Cochrane review of the newer antidepressants found in one study an increased risk of 58% of a suicide-related outcome for those on antidepressants, compared with placebo. In a group with average risk, this would equate to an increase from 25 in 1,000 to 45 in 1,000.
- The MHRA has stated that the risks of sertraline, citalopram, escitalopram, paroxetine, venlafaxine, and mirtazapine outweigh the benefits when used in children and adolescents with depression and should not be used in this patient group. However, it has been recognised that specialists may use these medications on occasions in response to individual clinical need.
- NICE recommends that tricyclics should not be used to treat depression in children and young people.
- The risk of suicide is greatest in the early stages of SSRI treatment. This may be due to the fact that the medications need to be taken for several weeks before they are effective in treating depression (which is itself associated with an increased risk of suicidal behaviour). Children and adolescents should be carefully monitored for any increase in suicidal behaviour, self-harm or hostility.
- Electroconvulsive therapy (ECT):
- Only consider ECT for young people (12-18 years) with very severe depression and either life-threatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments.
- ECT is used extremely rarely in young people (12-18 years) and only after careful assessment by a practitioner experienced in its use, and in a specialised environment.
- ECT should not be used in the treatment of depression in children (5-11 years).
- About 10% of children and young people with depression recover spontaneously within three months.
- 50% remain clinically depressed at twelve months and 20-30% at two years.
- Persistent depression in young people appears to have a permanent effect on personal function and personality.
- About 30% of young people with depression have recurrences within five years and many of these develop episodes into adult life.
- Female sex, increased guilt, previous episodes of depression, and parental psychopathology are associated with a worse prognosis.
- There is a prevalence of around 1-3% for medically serious suicide attempts in adolescents and a substantial risk of recurrence of suicidal behaviour ranging from 5-15%.
Preventative psychological and educational interventions may be effective. In a recent review of randomised controlled trials which had recruited children and young people aged 5 to 19 years, targeted and universal depression prevention programmes both prevented the onset of depressive disorders compared with no intervention.
Further reading and references
Self-harm in over 8s: short-term management and prevention of recurrence; NICE Clinical Guideline (2004)
Depression in children and young people: identification and management; NICE Guidance (June 2019)
Depression in children; NICE CKS, March 2016 (UK access only)
Williams SB, O'Connor EA, Eder M, et al; Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009 Apr123(4):e716-35.
Hawton K, Bergen H, Waters K, et al; Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study of self-harm in England. Eur Child Adolesc Psychiatry. 2012 Jul21(7):369-77. doi: 10.1007/s00787-012-0269-6. Epub 2012 Mar 25.
Cox GR, Callahan P, Churchill R, et al; Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev. 2014 Nov 30(11):CD008324. doi: 10.1002/14651858.CD008324.pub3.
Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs): use and safety; Medicines and Healthcare products Regulation Authority (MHRA), December 2014
Hetrick SE, McKenzie JE, Cox GR, et al; Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database Syst Rev. 2012 Nov 1411:CD004851. doi: 10.1002/14651858.CD004851.pub3.
Birmaher B, Williamson DE, Dahl RE, et al; Clinical presentation and course of depression in youth: does onset in childhood differ from onset in adolescence? J Am Acad Child Adolesc Psychiatry. 2004 Jan43(1):63-70.
Brent DA; Assessment and treatment of the youthful suicidal patient. Ann N Y Acad Sci. 2001 Apr932:106-28
Merry SN, Hetrick SE, Cox GR, et al; Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database Syst Rev. 2011 Dec 7(12):CD003380. doi: 10.1002/14651858.CD003380.pub3.