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Knowledge is Necessity
What every parent should know.
"Until a short while ago, our society refused to admit to depression in our children."
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When Your Child Feels Sad - Depression in Kids
There is an enemy in our midst, once thought only to attack adults and the elderly. Now it is openly preying on teens and children. The name of the monster is depression, and it is robbing ever increasing numbers of our off-spring of their childhoods and youth.
Some 3.4 million Americans under 18 have severe depression, one in every 33 children, according to estimates, and a staggering one in every eight teens, most who go undiagnosed and untreated.
According to Cynthia Pfeffer MD of Columbia
University, testifying at 2004 FDA public hearing into the safety and
efficacy of antidepressants in kids: Major depression affects approximately two percent of
children, and four to eight percent of adolescents. By the time a
youngster reaches age 18, there is a 20 percent prevalence rate for major
depression. "Since prior to World War II, each successive generation seems
to have a higher risk for major depressive disorder," she reported. The rate of
dysthymia (minor depression) is slightly lower and is often under-recognized,
she went on to say. Seventy percent
of youth with dysthymia break out into major depression, usually within
two to three years of the onset of dysthymia. Compared to adults,
adolescents have more behavioral problems. Psychotic depression occurs in
30 percent of youngsters with major depression. Atypical depression has
not been studied in kids. Co-occurring disorders may be present in up to
90 percent of youth with major depression, including dysthymia, anxiety,
disruptive behavior, and substance use.
Major depression affects approximately two percent of children, and four to eight percent of adolescents. By the time a youngster reaches age 18, there is a 20 percent prevalence rate for major depression. "Since prior to World War II, each successive generation seems to have a higher risk for major depressive disorder," she reported.
The rate of dysthymia (minor depression) is slightly lower and is often under-recognized, she went on to say. Seventy percent of youth with dysthymia break out into major depression, usually within two to three years of the onset of dysthymia. Compared to adults, adolescents have more behavioral problems. Psychotic depression occurs in 30 percent of youngsters with major depression. Atypical depression has not been studied in kids. Co-occurring disorders may be present in up to 90 percent of youth with major depression, including dysthymia, anxiety, disruptive behavior, and substance use.
The personal toll can be enormous: Homework not done, lessons not learned, ostracism by peers, alienation from family, run-ins with authority. A typical depressive episode can rage on for nine months or more, the length of a school year, enough time to brand a youth as undesirable and sabotage forever his or her brightest hopes and dreams. Six to 10 percent of kids with major depression have a protracted course, 40 to 60 percent relapse after remission, and 20 to 60 percent have recurring episodes after recovery.
The victim may retreat into his or her inner world or take comfort in alcohol or illegal drugs. Or the opposite may happen in the form of aggressive behavior that has neighbors dialing 911.
Ultimately, all too many seek the wrong way out: CDC data from 2001 found that 19 percent of high school students had seriously considered attempting suicide, nearly 15 percent had made plans to attempt suicide, and almost 9 percent had made a suicide attempt the preceding year. A 1993 nine-year study by Kovacs et al found children with major depression had a 74 percent rate of suicidal thinking and a 28 percent rate of suicide attempts. The percentages were about the same for those with dysthymia.
Since the 1950s, youth male suicide rates in the US increased three-fold. In 2000, 1,921 US kids under age 20 died by suicide, the third leading cause of death in our youth. Fortunately, there has been a sharp decline starting in 1994 and around the same time in other industrialized nations, possibly related to teens being prescribed SSRIs..
Until a short while ago, our society refused to admit to depression in our children, much less acknowledge they had anything to be depressed about. Deborah Deren, on her Wing of Madness web site, describes addressing a group of classmates a number of years back, many experienced teachers: "I was saddened," she writes, "though not surprised, by the number of them who told me after class that they had no idea children could suffer from depression."
She adds: "Although many myths and misunderstandings surround adult depression, even more surround childhood depression."
All too often, parents fail to recognize the symptoms or respond with ill-advised boot-in-the-backside remedies. Syndicated columnist Kathleen Parker is a case in point: "My guess is," she writes, "we wouldn't have most of today's crop of afflictions - drug abuse, promiscuity, attention deficit disorder, violence - if we'd take a break from examining our navels and starting kicking a little anatomy."
Perhaps, before we start kicking, we should start paying attention. According to a survey of near-suicides, parents perceived depression in their children only 13 percent of the time (versus 57 percent subsequently diagnosed).
Making matters worse is the fact that kids, ever sensitive to stigma, are not inclined to speak up. According to Harold Koplewicz MD of NYU, speaking at a 1999 White House Conference on Mental Illness: "Teenagers are never volunteering to be customers for mental health services."
That is, assuming these services are available. In many states Medicaid does not pick up the tab.
As to why kids get depressed, all the usual suspects are trotted out: the stresses and strains of modern life, working parents, broken homes. Poor kids are at greater risk due to more environmental stressors, but well-off kids are hardly immune. After a certain age, girls become far more likely victims in much greater numbers, probably due to concerns about their appearance and fitting in.
But the terrible truth is we simply don't know. Child psychiatry lags behind our knowledge of both psychiatry as a whole and other childhood illnesses, this despite the great need to find out how young brains work, which are not simply miniature replicas of our own.
Signs of Depression in Kids
Following are some of the danger signs, according to the
National Alliance for the
But wait. Before you rush your child to get treatment, there are things you should know: Early-onset depression often co-occurs with other disorders, such as attention deficit disorder or as a prelude to bipolar disorder. Prescribing an antidepressant in either of these cases may well send your child bouncing off walls.
Should Kids with Depression Take Antidepressants?
Antidepressants were designed for adult brains, but in Jan 2003, following two successful trials, the FDA approved Prozac for kids seven to seventeen, the first and only antidepressant indicated for such use. Prior to this, these drugs had been used "off label" for this population. Nevertheless, the FDA was worried about one of the trials that found the Prozac kids gained two pounds less and grew half-inch less after 19 weeks than those on placebos. Eli Lilly has promised to do more studies. Several other antidepressants have failed in clinical trials in children, and have raised concerns over their safety, resulting in two highly-publicized FDA public hearings in 2004 and a new black box warning on the product labeling (see article).
The reported safety data from the FDA and its UK counterpart, the MHRA, although spotty, revealed that 6.1 percent of the kids in the Prozac trials experienced hyperactivity, 3.1 agitation, and 2.6 had manic or hypomanic reactions (vs hardly any or zero in the placebo groups). Although the FDA did not connect these effects to suicidal behavior, in October 2004 it instructed manufacturers to warn on the product labeling that kids on antidepressants need to be carefully monitored as "there is concern that such symptoms may represent precursors to emerging suicidality."
An FDA analysis of 25 pediatric trials involving 4,000 patients found “out of 100 patients treated we might expect two to three patients to have some increase in suicidality due to short-term treatment ... that is beyond the risk that occurs with the disease being treated.”
But in a study published in the Oct 2003 Archives of General Psychiatry, researchers from Columbia University reviewed 588 case files of kids aged 10 to 19 and found that a one percent increase in antidepressant use was associated with a decrease of 0.23 suicides per 100,000 adolescents per year, suggesting that your depressed child is probably a lot safer on antidepressants than off them.
The best way to assess the benefits vs risks and ensure optimal meds care for your child is to consult a psychiatrist, ideally one with a specialty in pediatric psychiatry. At the FDA hearings, parents came forward numerous examples of primary care physicians who failed to warn parents of the potential adverse effects of these drugs and provide proper follow up. If a primary care physician is your only option, make sure he or she has some basic competence in treating kids for depression.
An informed parent working closely with a psychiatrist can greatly minimize the risk. Keeping a watchful eye out for strange behavior can be difficult with a teen - who are strange by definition - but when in doubt call your psychiatrist immediately.
A 2004 NIMH study of 439 youths found Prozac helped teens overcome depression far better than talking therapy, and that the greatest success came when the two treatments were combined. After 12 weeks, 43 percent responded to talking therapy, 61 percent to Prozac, and 71 percent to combination Prozac-talking therapy.
Even though other antidepressants have not been successful in pediatric clinical trials, it may be appropriate to prescribe them off-label to kids in certain situations. The FDA does not forbid the practice, but you are entitled to a clear explanation from your child's psychiatrist.
Parents have the power to make a huge positive difference. According to Los Angeles therapist Judith Harris, in an article in USA Today: "Kids who beat depression often have parents willing to listen with care and perhaps for the first time embrace a child who isn't the kid they hoped for."
Kids' Depression Guidelines for Parents
Following are some common sense guidelines for parents:
For further information, the National Alliance for the Mentally Ill has a hotline: (800) 950-6264.
For a national hotline: 1-800-333-4444
For a directory of local hotlines, visit About.com.
Browse friends and family books here.
For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.
Updated Nov 5, 2004.
Leon (Oct 29, 2004): An experience I am writing this time not about the spelling of the word glue in German or its etymology but about a specific practical concern regarding the methods applied to diagnose and treat the child depression. Perhaps after disguising some of the data you can share this account with your readers as it might be of interest to the larger audience. As always my appreciation for the great job you are doing.
My 10 year old son has been brought by his mother (herself a somewhat depressed person) to a Harvard psychiatrist who quickly diagnosed him with the “major depression”. At the very beginning, I did not even know that my son was being seen by the clinician as I was separated from my wife and children pending a divorce case. I know for sure that my both children were very upset (the 8 yr. old who is seeing another Harvard psychiatrist was diagnosed with ADHD but not depression) about that situation and did not want the parents to divorce (especially the older one). Nor did they like the restrictions imposed on the frequency and nature of their contact with the father. Under these circumstances, it appeared (to me) quite understandable that the boy was unhappy and accordingly expressed his feelings to the parents and the doctor. At the same time, at school he was doing very well, did not have any trouble sleeping at night, was active playing his computer and other games and quite talkative as usual. My son sees the doctor once a week and follows the psychodynamic therapy. The doctor, nevertheless insists from time to time that he should prescribe Prozac to my son which my child himself opposes.
Only after several months after treatment started have I had a full-fledged conversation with the doctor about my son’s condition. Some of the comments I heard are mind boggling. I first asked about the diagnosis and specifically inquired whether he applies Children’s Depression Rating Scale (CDRS) to determine patient’s condition. The answer was “yes” and “no” with the suggestion that CDRS is more for research purposes and the doctor himself relies heavily on his experience. He himself candidly admitted that it was still a “fuzzy knowledge” but when asked about the symptoms he was looking for (and which the parents could monitor as well) he mentioned slow-talking, sadness in facial expressions, over eating, poor progress at school on the top of the mood indicators. The point is that my son has been eating very well since he was 3 and he has been somewhat overweighed for a long time, he has been doing well at school since the first grade. Overall, he feels much more positive now when he has regular contact with the father, the divorce proceedings have been put on hold and it looks like there is a good chance for reconciliation between the parents.
Yet the doctor notices that my son has his “ups” and “downs”. Consequently, he from time to time comes with the Prozac solution emphasizing that the experience shows it cannot be harmful. When asked whether he would go and watch my son at school, the doctor says he’s busy and the insurance does not pay for it. It is further unclear how the doctor processes information from us the parents who obviously have more opportunities to observe the child’s behavior.
The most important and scary part is that once the rather incomplete diagnosis of “depression” has been concluded, what follows is a play-safe approach which in my opinion, has little to do with the real treatment—the doctor quoted that 6% of the depressed children eventually harm themselves and wants to take precautions.
I would really appreciate it if I could get any comments from you and your readers.
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