Adolecsent Depression

The suicide rate for adolescents has increased more than 200% over the last decade. Recent studies

have shown that greater than 20% of adolescents in the general population have emotional

problems and one-third of adolescents attending psychiatric clinics suffer from depression. The

majority of teenage depressions can be managed successfully by the primary care physician with

the support of the family, says Maurice Blackman MB, FRCPC.

Depression has been considered to be the major psychiatric disease of the 20th century, affecting approximately eight million

people in North America. Adults with psychiatric illness are 20 times more likely to die from accidents or suicide than adults

without psychiatric disorder.[1] Major depression, including bipolar affective disorder, often appears for the first time during the

teenage years, and early recognition of these conditions will have profound effects on later morbidity and mortality.

Is depression in adolescents a significant problem?

The suicide rate for adolescents has increased more than 200% over the last decade.[2] Adolescent suicide is now responsible

for more deaths in youths aged 15 to 19 than cardiovascular disease or cancer. Recent studies have shown that greater than

20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics

suffer from depression.[3] Despite this, depression in this age group is greatly underdiagnosed, leading to serious difficulties in

school, work and personal adjustment which often continue into adulthood.

Why is depression in this age group often missed?

Adolescence is a time of emotional turmoil, mood lability, gloomy introspection, great drama and heightened sensitivity. It is a

time of rebellion and behavioral experimentation. The physician's challenge is to identify depressive symptomatology which may

be superimposed on the backdrop of a more transient, but expected, developmental storm.

Diagnosis, therefore, must rely not only on a formal clinical interview but on information provided by collaterals, including

parents, teachers and community advisors. The patient's premorbid personality must be taken into account, as well as any

obvious or subtle stress or trauma that may have preceded the clinical state. The therapeutic alliance is very important since the

adolescent will not usually readily share his/her feelings with an adult stranger unless trust and rapport are established.

Confidentiality must be assured, but not to the point that the parents - who are often essential allies in treatment - are wholly

excluded. Diagnosis may require more than one interview and is not a process that can be rushed. Inquire directly about

possible suicidal ideation.

What are the common symptoms of adolescent depression?

Depression presents in adolescents with essentially the same symptoms as in adults; however, some clinical shrewdness may be

required to translate the teenagers' symptoms into adult terms. Pervasive sadness may be exemplified by wearing black clothes,

writing poetry with morbid themes or a preoccupation with music that has nihilistic themes. Sleep disturbance may manifest as

all-night television watching, difficulty in getting up for school, or sleeping during the day. Lack of motivation and lowered energy

level is reflected by missed classes. A drop in grade averages can be equated with loss of concentration and slowed thinking.

Boredom may be a synonym for feeling depressed. Loss of appetite may become anorexia or bulimia. Adolescent depression

may also present primarily as a behavior or conduct disorder, substance or alcohol abuse or as family turmoil and rebellion with

no obvious symptoms reminiscent of depression.

Formal psychologic testing may be helpful in complicated presentations that do not lend themselves easily to diagnosis. In the

most difficult cases, a trial of treatment may be required to differentiate clinical depression from extreme developmental turmoil

or conduct disorders.

How can suicide risk be determined?

It is not uncommon for young people to be preoccupied with issues of mortality and to contemplate the effect their death would

have on close family and friends. Thankfully, these ideas are usually not acted upon. Suicidal acts are generally associated with a

significant acute crisis in the teenager's life and may also involve concomitant depression. It is important to stress that the crisis

may be insignificant to the adults around, but very significant to the teenager. The loss of a boyfriend or girlfriend, a drop in

school marks or a negative admonition by a significant adult, especially a parent or teacher, may be precipitant to a suicidal act.

Suicidal ideation and acts are more common among children who have already experienced significant stress in their lives.

Significant stressors include divorce, parent or family discord, physical or sexual abuse and alcohol or substance abuse. A

suicide in a relative or close friend may also be an important identifier of those at the greatest risk. The teenager who exhibits

obvious