Depression

by Nadja Reilly, Ph.D, Associate Director, Freedman Center for Child and Family Development, Massachusetts School of Professional Psychology

What is Depression?

It is normal to feel “sad” or “blue” at times. Depression is different from these temporary feelings. Depression is a biological illness that presents with sad mood, loss of interest or pleasure, feelings of guilt or worthlessness, difficulty concentrating, low energy, changes in sleep and appetite, and sometimes thoughts of suicide.

• Clinical depression is a biological, treatable illness that involves abnormal functioning of the brain’s chemicals that affects a person’s emotions, thoughts, energy, sleep, concentration and impairs how they feel about themselves and their relationships and the world.
• Depression is an illness and therefore someone cannot “just get over it.”
• Depression is a family illness. If one person in a family suffers from depression it affects the entire family.
• Peak years of onset of depression: 16-24 years old.
• After age 15, girls and women are twice as likely as boys and men to have depression.

Where Does Depression Come From?

There is no single cause of major depression. Psychological, biological, and environmental factors may all contribute to its development. Sometimes depression is not due to any single identifiable trigger. Risk factors, or potential factors that contribute to the development of depression, include loss of a loved one; emotional, physical, or sexual abuse; being the victim of violence or harassment; chronic stress; alcohol and drug abuse; family conflict, academic and social pressures, and health problems. Scientists have also found evidence of a genetic predisposition to major depression. While not everyone with a genetic predisposition develops depression, there is an increased risk for developing depression when there is a family history of the illness.

What Does Depression Look Like in Adolescents?

The chart below lists symptoms frequently seen in adolescents who suffer from depression.

When a teenager is experiencing significant emotional distress, severe symptoms without improvement for at least two weeks, and there is an impairment of functioning across all life domains (school, home, peers, health), the teen is likely suffering from clinical depression.

There are some differences noted in which symptoms are most prominent based on age.

Younger adolescents (10-14 years)

• more anxiety symptoms: fearfulness and nervousness
• clinging behaviors
• physical symptoms (headaches, stomachaches)

Older Adolescents (14 to 18 years)

• loss of interest and pleasure
• more negative self thoughts
• increased thoughts of death and suicide

Depression & Negative Thoughts

The painful thoughts and feelings associated with depression can be quite debilitating. Many teenagers who suffer from depression have used the words such as “broken,” “hollow,” “damaged,” and “empty” to describe their internal experience of depression. They may say things like “Nothing will ever get better.” (hopelessness); “I wish I was never born.” (worthlessness); and “Nobody loves me or cares about me.” (distorted thoughts).

Teenagers suffering from depression view the environment as overwhelming, with obstacles that cannot be overcome, and as continually resulting in failure or loss. They may feel like they are not worth loving, are not smart enough, are not good enough, and generally will be a disappointment. Teenagers who suffer from depression may express significant guilt about having failed others or feelings of guilt related to being the source of all problems.

How is Depression Treated?

It is difficult for people who are struggling with depression and suicidal thoughts to reach out for help. They may feel ashamed or embarrassed, they may feel like they do not want to burden others; or perhaps they feel hopeless, which in turn makes them think that they cannot get better. In some cases, people may not realize that they are suffering from an illness and think that “it is just the way they are.” Frequently, people may not get help because they do not know how to access help or who to turn to. What can you do to help yourself or others? Get educated about the treatment of depression!

• Depression is a highly treatable illness. However, in the United States, only one-third of people with depression receive treatment.
• Treatment: The first step is realizing that something is wrong, that the thoughts, feelings, sleep and energy disturbance will not go away on their own. The second step is recognizing that help is available and that treatment works.
• Psychotherapy and medications have been shown to be effective treatments. Usually, psychotherapy is tried first. If the person does not improve, or if the person is so depressed that he or she is thinking about harming himself/herself, then medication is also used.
• Counseling can help focus on changing thinking, problems in relationships, and can help the person develop better ways to deal with stress.
• Learning to challenge negative, distorted thoughts is an important skill to decrease depression. This is called Cognitive Behavioral Therapy (CBT) and there are many books available to the public about this form of therapy. CBT has been proven to be very effective in treating depression.
• Couples therapy can improve relationships, help parents to communicate, understand depression, divide tasks and enlist more support for the children.
• Family therapy can help family members understand depression and to learn how to better support each other. Children will feel better that problems are being addressed and will learn to communicate with parents and ask for help.
• Group therapy can sometimes be helpful as well, as patients are able to interact with others and know that they are not alone in the illness.
• Early treatment can be a protective factor.
• Having close, intimate confiding relationships is a protective factor.
• Cardiovascular exercise can help manage depression and anxiety. Movement is important as is going for a walk, both for the exercise, but also the contact with nature and other people.
• Volunteering to help others can remind someone who is depressed about their own strengths and capacity to contribute.

Use of Medication

Studies have shown that combination of medication and psychotherapy (i.e. Cognitive behavior therapy) is the most effective treatment. Electroconvulsive therapy may also be an option.

• The first line of medications are the SSRI’s (selective serotonin reuptake inhibitors) which include fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).
• Other common first choices for antidepressants include serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), combined reuptake inhibitors and receptor blockers, and tetracyclic antidepressants.
• Second line of medications includes a class of antidepressants called tricyclic antidepressants (TCAs). TCA have been around longer than the SSRI’s but are used as second line because they tend to have undesirable side effects.
• Last choice of medications includes a class of antidepressants called monoamine oxidase inhibitors (MAOIs). These medications like the TCA’s are very effective but are not the first choice in treatment because of their potential serious side effects and strict dietary restrictions due to potentially fatal interactions with certain foods.

It is important to remember that your doctor may recommend any combination of the above in addition to other “off label use” of other medications that include mood stabilizers, anxyolitics, stimulants, and antipsychotics. What are the most serious side effect of SSRI’s? Generally speaking the SSRI’s are safe to take. But you have to be aware of the “black box warning.” Studies showed that in some cases children, adolescents and young adults ages 18 to 24 that were taking SSRI may have an increase in suicidal thoughts or behavior when they first started the medication or when the medication was changed. It is important to be aware of this so that you and those around you can get you the help you need if this happens to you.

Additional Sources of Information

General

Major Depression in Children and Adolescents, from SAMHSA's National Mental Health Information Center.

For Parents

• Medication Guide for Treating Depression, from ParentsMedGuide, a collaboration of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.
• The Depression Wellness Guide for Parents (pdf), from Families for Depression Awareness, www.familyaware.org.
• Parent Resources, from Adolescent Wellness, Inc.
• Drinking, Drugs and Depression: Prevention and Help for Your Child
• The Depression Experience Journal

For Children and Teens

• The Depression Wellness Guide for Teens (PDF), from Families for Depression Awareness, www.familyaware.org.
• Depression: Resources For and About Teens