“Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and sometimes you may feel as if life isn’t worth living” (Mayo Clinic 2019).
Depression isn’t a weakness, or feeling blue, and you can’t simply “snap out” of it. Depression is serious and can have far reaching effects on the functioning and development of children/teenagers and place them at an increased risk of interpersonal and psychosocial difficulties, self harm behaviour, other mental illnesses (anxiety disorder, behaviour disorder), substance abuse and suicidal behaviour. Depression usually requires long-term treatment and supports. However, the good news is that with early identification and intervention, 70 to 90 percent of children/teenagers will experience significant reduction in symptoms, and 45 to 60 percent will have a complete recovery.
It is estimated that up to 2.5 percent of children and up to 8.3 percent of teenagers in the USA have depression. Every year, up to 80 percent of children/teenagers with depression are hospitalized at a cost of $247 million. In Canada, approximately 5 percent of males and 12 percent of females age 12 to 19 yrs. have major depressive disorder. It is estimated the total number of Canadian teenagers age 12 to 19 yrs. at risk for developing depression is 3.2 million. Globally, major depressive disorder in children/teenagers has increased significantly. Sadly, with the increase in depression, the number of children and teenagers ending their lives by suicide has also increased dramatically, with suicide now being the second leading cause of death in kids ages 5 to 24 years.
- Family history of depression and/or suicide
- Loss of parent (death/divorce), family member, beloved pet
- Pre-existing conduct disorder, learning disorder, ADHD, OCD, ASD
- Abuse/neglect: sexual, physical, emotional (think ACE’s from Blog #2)
- Pre-existing illness e.g. diabetes
- Exposure to a traumatic experience e.g. car accident, school shooting, natural disaster
- Repeated bullying
- Break up of a romantic relationship
- General Signs and Symptoms of Depression
- Persistent sad or irritable mood
- Loss of interest in activities
- Significant change in appetite, body weight
- Sleeping difficulties
- Loss of energy, persistent fatigue
- Difficulty concentrating
- Feelings of worthlessness
- Thoughts of death or suicide
- Moody, agitated
The general consensus is that five or more of the above symptoms must persist for two weeks or more before a diagnosis of major depressive disorder in made. If a child/teenager screens positive on any of these tests, then a comprehensive diagnostic assessment and evaluation by a Mental Health Professional is required.
Other Signs and Symptoms Specific to Children/Teenagers
- Frequent, non-specific complaints e.g. headaches, muscle aches, stomach problems
- Frequent absenteeism from school and/or failing grades
- Outbursts of shouting, crying, screaming, unexplained irritability
- Lack of interest in friends, social activities, family gatherings
- Increased social isolation
- Extreme sensitivity to failure, rejection
- Noted change in communication, appearance, hygiene, body language
- Reckless, risky behaviour
- Alcohol and/or substance abuse, cigarette smoking
- Self – harm (NSSI)
- Sudden fear of death, unusually needy or clingy
- Talks about running away from home, no-one cares, better off dead
Screening for Depression
- Children’s Depression Inventory (CDI) for ages 7 to 17 years https://www.aafp.org/afp/2012/0901/afp20120901p442-f1.gif
- Beck Depression Inventory (BDI) for adolescents
- Center for Epidemiologic Studies Depression Scale (CES-D)
- Psychotherapy: cognitive behavioural therapy (CBT), family therapy, individual therapy, interpersonal therapy
- Medications: anti-depressants (SSRI’s) have been found to be effective when used short-term and combined with psychotherapy
- Lifestyle choices: healthy diet, exercise, fluids, creative expression e.g. journaling, music, art, reduced time on social media, restful sleep
- Youth support groups may also be helpful
- Play therapy is very effective for children
What Parents Can Do
- Be there: listen, support, show love
- Be patient and understanding
- Ensure treatment plan is followed
- Participate in therapy: enlist support of family, siblings, friends
- Discuss plan of care with school
- Promote safety: remove firearms, secure medications and alcohol, remove sharp objects, lock up toxic liquids
- Encourage child/teenager: life with depression is one step at a time. Validate fears and concerns, promote positive self talk and affirmation
- Do not blame, ridicule, invalidate or ignore behaviour
- Monitor for signs of suicidal behaviour (see Blog#13) and respond immediately to any threat or action
- Establish daily routine and promote healthy lifestyle choices
- Spend one on one time with child/teenager, be objective, non-judgemental, show compassion, encourage hope for the future
- Observe for side effects of medications, report immediately, do not stop medications unless directed by physician
Treatment Resistant Depression in Children and Teenagers: The Role of Ketamine, ECT and CBD Oil
Unfortunately, up to 40 percent of children/teenagers do not respond to antidepressants which lowers their chance of remission, increases their risk of suicide and of developing a substance use disorder. In 2019, the FDA approved the use of Ketamine (an anesthetic and street drug, known as Special K) for treatment resistant depression. Ketamine activates the part of the brain that regulates emotions and promotes neural plasticity
Depression is thought to be caused by reduced connections between certain neurons (nerve cells) in the brain and a build up of G-proteins on top of these nerve cells. This ‘pile up’ prevents the movement of brain signals. Antidepressants notably SSRI’s help to shift the G-proteins unblocking congestion within an hour. However, Ketamine can remove the build up in 15 minutes and can be administered via IV infusion or nasal spray. The drug must be administered in a medical office under medical supervision. To date, clinicals trials have found Ketamine to be fast acting, long lasting, with a significant reduction in suicidal ideation. Whilst this is encouraging news, it must be pointed out that Ketamine has many side effects e.g. feelings of dissociation, hallucinations, confusion, lowers blood pressure and as it is a controlled substance, there is the increased risk of dependency and/or addiction.
An alternative to Ketamine, is Electroconvulsive Therapy (ECT). Recent studies have found that ECT in teenagers yielded positive results. The procedure is easily tolerated, side effects are minimal e.g. temporary amnesia and the majority of teenagers with severe, treatment resistant depression went into remission and were able to resume pre-depression activities almost immediately.
There has been a lot of talk lately about CBD oil (cannabidiol) for the treatment of depression in children and teenagers. The marijuana plant comprises two compounds: THC the psychoactive, get ‘high’ part and CBD where one does not get ‘high.’ It is believed that CBD oil can lessen the effects of depression and increase happiness. It works by interacting with the endocannabinoid system (a collection of cell receptors such as serotonin and dopamine and the corresponding molecules, called agonists in the brain which help regulate sleep, appetite, mood, pain and pleasure). Whilst CBD oil has been found to be very effective in the treatment of epilepsy, seizures and ADHD, no long-term research has been conducted into its effect on depression and anxiety.
I think it is important that anyone considering trying any of these treatments for a child/teenager speak with the physician/psychiatrist first. Remember, for every success story, there is also a child/teenager that was not helped by any of these treatment resistant options. Side effects, both short-term and long-term must be reviewed, contraindications, risks and benefits must also be discussed including cost, legality and ongoing assessment and monitoring.
In my next Blog #16
In recognition of Bullying Prevention Awareness month,
I will be discussing the different types of bullying behaviour and identifying who is the bully