Depressive disorders, which include major depressive disorder (unipolar depression), dysthymic disorder (chronic, mild depression), and bipolar disorder (manic-depression), can have far reaching effects on the functioning and adjustment of young people. Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents there is also an increased risk for substance abuse and suicidal behavior.^{1, 2, 3} Unfortunately, these disorders often go unrecognized by families and physicians alike. Signs of depressive disorders in young people often are viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely "label" a young person with a mental illness diagnosis. Yet early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development.

Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that concerning adults, a number of studies—mostly conducted in the last four to five years—have confirmed the short-term efficacy and safety of treatments for depression in youth. Larger treatment trials are needed to determine which treatments work best for which youngsters, and studies are also needed, however, on how to best incorporate these treatments into primary care practice.

Given the challenging nature of the problem, it is usually advisable to involve a child psychiatrist or psychologist in the evaluation, diagnosis, and treatment of a child or adolescent in whom depression is suspected.

This fact sheet, prepared by the National Institute of Mental Health (NIMH), the lead Federal agency for research on mental disorders, summarizes some of the latest scientific findings on child and adolescent depression and lists resources where physicians can obtain more information.

Scope of the Problem

A number of epidemiological studies have reported that up to 2.5 percent of children and up to 8.3 percent of adolescents in the U.S. suffer from depression.⁴ An NIMH-sponsored study of 9- to 17-year-olds estimates that the prevalence of any depression is more than 6 percent in a 6-month period, with 4.9 percent having major depression.⁵ In addition, research indicates that depression onset is occurring earlier in life today than in past decades.⁶ A recently published longitudinal prospective study found that early-onset depression often persists, recurs, and continues into adulthood, and indicates that depression in youth may also predict more severe illness in adult life.³ Depression in young people often co-occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, ⁷ and with physical illnesses, such as diabetes.⁸

Suicide: Depression in children and adolescents is associated with an increased risk of suicidal behaviors.^3,9 This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.¹⁰ In 1997, suicide was the third leading cause of death in 10- to 24-year-olds.¹¹ NIMH-supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may commit suicide in the young adult years.³ Consequently, it is important for doctors and parents to take all threats of suicide seriously.

NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limiting young people's access to lethal agents—including firearms ¹² and medications—may hold the greatest suicide prevention value.

Clinical Characteristics

The diagnostic criteria and key defining features of major depressive disorder in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder may be more difficult in youth for several reasons. The way symptoms are expressed varies with the developmental stage of the youngster.^{1, 2} In addition, children and young adolescents with depression may have difficulty in properly identifying and describing their internal emotional or mood states. For example, instead of communicating how bad they feel, they may act out and be irritable toward others, which may be interpreted simply as misbehavior or disobedience. Research has found that parents are even less likely to identify major depression in their adolescents than are the adolescents themselves.¹³

Symptoms of Major Depressive Disorder Common to Adults, Children, and Adolescents¹⁴

• Persistent sad or irritable mood
• Loss of interest in activities once enjoyed
• Significant change in appetite or body weight
• Difficulty sleeping or oversleeping
• Psychomotor agitation or retardation
• Loss of energy
• Feelings of worthlessness or inappropriate guilt
• Difficulty concentrating
• Recurrent thoughts of death or suicide

Five or more of these symptoms must persist for 2 or more weeks before a diagnosis of major depression is indicated.

Signs That May Be Associated with Depression in Children and Adolescents

• Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomachaches or tiredness
• Frequent absences from school or poor performance in school
• Talk of or efforts to run away from home
• Outbursts of shouting, complaining, unexplained irritability, or crying
• Being bored
• Lack of interest in playing with friends
• Alcohol or substance abuse
• Social isolation, poor communication
• Fear of death
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Reckless behavior
• Difficulty with relationships

While the recovery rate from a single episode of major depression in children and adolescents is quite high ¹⁵, episodes are likely to recur.¹⁶ In addition, youth with dysthymic disorder are at risk for developing major depression.¹⁷ Prompt identification and treatment of depression can reduce its duration and severity and associated functional impairment.