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					                                                                         1.
Depression

People with social anxiety often suffer from depression. According to the
World Psychiatric Association (1995), 17% of social anxiety sufferers also have
major depression. Unfortunately many people who are suffering depression go
undiagnosed and untreated. If you are so depressed that your motivation is
low and you feel hopelessness about the possibility of overcoming your social
anxiety, it may interfere with treatment. Therefore, sometimes depression
needs to be treated before social anxiety can be tackled.

The symptoms of depression include:

      lowered mood, feelings of sadness or emptiness
      changes in sleep
       Depressed people may have difficulty falling asleep and typically wake
       up in the middle of the night and have difficulty resuming sleep.
       Depressed people may also find they wake early in the morning and
       can't resume sleep. Other depressed people find that they are sleeper
       longer than is usual for them at night or that they are having increased
       sleep during the daytime.
      marked increase or decrease in appetite and associated weight loss or
       weight gain
      thoughts of self harm or suicide
      decreased motivation
      lack of energy
      thoughts of uselessness, worthlessness, hopelessness or inappropriate
       guilt
      feeling agitated or slowed down
      poor concentration and memory and difficulty making decisions 2.
      decreased enjoyment of or loss of interest in activities previously found
       pleasurable or important such as work, hobbies, sport

If you think you may be depressed seek advice from your doctor and/or
psychologist.

American Psychiatric Association.(1994). Diagnostic & Statistical Manual of
Mental Disorders DSMIV. Washington, DC: American Psychiatric Press

Montgomery, S.A. (1995). Pocket Reference to Social Phobia London. Science
Press Ltd.

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Child and Adolescent Depression:
Diagnosis and Treatment
                                       :                      4.

Depression in Children and Adolescents
Carol E. Watkins, M.D.




Childhood and adolescent depression increased dramatically in the past forty to fifty years. The
average age of onset has fallen. During childhood the number of boys and girls affected are
almost equal. In adolescence, twice as many girls as boys are diagnosed. (Similar to adult rate)
Repeated episodes of depression can take a great toll on a young mind. Well over half of
depressed adolescents have a recurrence within seven years. Children with Major Depression
have an increased incidence of Bipolar Disorder and recurrent Major Depression.

Characteristics of child and adolescent depression

In many ways, the symptoms are similar to those of adult depression. In the DSM-IV, the
criteria for childhood and adult Major Depression are the same. Children may not have the
vocabulary to talk about such feelings and so may express their feelings through behavior.
Younger individuals with depression are more likely to show phobias, separation anxiety
disorder, somatic complaints and behavior problems. With psychotic depression, children are
more likely to report hallucinations. Older adolescents and adults with psychotic depression are
more likely to have delusions. (Delusions require more advanced cognitive functioning than
simple hallucinations)

One might observe the following external signs in a depressed child or adolescent.

      Preschool or young elementary age: The child might look serious or vaguely sick. He
       might be less bouncy or spontaneous. While other children would become tearful or
       irritable when frustrated, this child may show these states spontaneously. He may say
       negative things about himself and may be self-destructive.
      Older elementary school through adolescence: The adolescent may present with
       academic decline, disruptive behavior, and problems with friends. Sometimes one can
       also see aggressive behavior, irritability and suicidal talk. The parent may say that the
       adolescent hates himself and everything else.

Causes of Depression

How much is due to heredity and how much to environmental issues? Things associated with
childhood depression include inconsistent parenting, stressful life experiences, and a negative
way of viewing the world. Childhood depression is also associated with a family history of mood
disorders and with the existence of other psychiatric conditions If the relative has had childhood
or recurrent depression, the child is at even higher risk of developing depression. There are
different theories on the causes of depression. Some feel that children inherit a predisposition
to depression and anxiety but that environmental triggers are necessary to elicit the first
episode of Major Depression.

When depressed adults are asked about their childhood experiences, they are more likely to
report neglect, abuse rejection and parental conflict.

Consequences and Associated Conditions

Many children with depression have one or more other major psychiatric diagnoses. Anxiety
Disorder, Substance Abuse, and ADHD are frequently associated with childhood depression.
ADHD might be present before the first episode of depression and can complicate the treatment
of both conditions. Substance abuse often starts after the first episode of depression, although
this can vary in different individuals. The other conditions may persist even after the major
depressive episode passes, and can render the individual more vulnerable to a recurrent
depression. Children with depression accompanied by ADHD or Conduct Disorder are more
likely to have adult criminal records and suicide attempts than individuals with depression
alone.

Depression is associated with school and interpersonal problems. It is also correlated with
increased incidence of suicidal behavior, violent thoughts, alcohol, early pregnancy, tobacco
and drug abuse.

Depression can lead to an increased chance of suicide attempts and successful suicides. Since
1950, the adolescent suicide rate has risen four fold 12% of the total adolescent mortality in
1993 was due to suicide. Suicide is not always associated with MDD. Usually those who
attempt suicide have more than one problem. One should be especially vigilant with those who
have a relative who committed suicide or who are exposed to family violence.



Family Issues

Depressed children often have depressed or stressed parents. Can the stress of coping with a
depressed child lead to parental rejection or is it the poor parenting that leads to the child's
depression? The answer may be different in different cases. A depressed, hyperactive child
may be hard to raise. Some parents have more coping skills than others. A child may learn to
give up because parents have not modeled good ways of coping with stressful situations..
Some suggest that parental patterns of irritability, and withdrawal lead to low self-esteem in the
child and that this predisposes the child to depression. Some suggest that a genetically
vulnerable child is more likely to develop depression when exposed to family stress.

Diagnosis

It usually takes more time to diagnose Major Depression in a child than it does to diagnose an
adult. The diagnostic process should include interviews of parents and the child. I try to include
both parents, even if the child is only living with one parent. Parents are more likely to report
outward signs of depression. The child may be more aware of inward signs. Sometimes a
parent's report is skewed by the parent's own agenda, so school and other outside reports are
useful. (with written permission) Generally, there should be a recent physical. Although this is
usually done by the primary care physician, the psychiatrist may do a screening neurological
and relevant parts of a physical exam. The psychiatrist will ask about the developmental history
and about the existence of other psychiatric conditions.

Treatment

There is no cookbook technique. Treatment must be tailored to the needs and schedule of the
child and his family. Generally, with mild to moderate depression, one first tries psychotherapy
and then adds an antidepressant if the therapy has not produced enough improvement. If it is a
severe depression, or there is serious acting out, one may start medication at the beginning of
the treatment.

Psychotherapy

A variety of psychotherapeutic techniques have been shown to be effective. There is some
suggestion that cognitive-behavioral therapy may work faster. Cognitive therapy helps the
individual examine and correct negative thought patterns and erroneous negative assumptions
about himself. Behaviorally, it encourages the individual to use positive coping behaviors
instead of giving up or avoiding situations. After therapy is over, children may benefit from
scheduled or "as-needed" booster sessions.

Many feel that family therapy can speed recovery and help prevent relapse. There are different
styles of family therapy.

Medication

Most studies suggest that the older, tricyclic antidepressant medications (Amitryptiline,
Imipramine Desipramine) are no better than placebo in the treatment of depression. Still, many
of us have seen individual children and adolescents who have responded well. Tricyclic
antidepressants can be an effective treatment for ADHD. Since there is a small risk of heart
rhythm changes, in children on these medications, we usually follow EKGs. The usefulness of
blood tricyclic levels is being debated.

SSRIs (Selective Serotonin Reuptake Inhibitors--Prozac, Zoloft etc.) improved the limited
outlook for the medication treatment of child and adolescent depression. The side effects are
not as annoying as those of the older medications. These medications are less toxic in
overdosage. Fluoxetine (Prozac) has been approved by the FDA for the treatment of
depression in children 8 and up. There is special concern about using paroxetine (Paxil) or
venlafzxine (Effexor) with depressed children and adolescents. In the fall of 2004, the FDA (US
Food and Drug Administration) issued a black box warning that will be placed on all
antidepressant medications. The warning notes that antidepressant use has been associated
with suicidal behavior in some children and adolescents. This warning was based on a review
of all available controlled studies of antidepressants in children. Expect physicians to insist on
closer monitoring of children who are taking these medications.

As compared to adults, adolescents are a bit more likely to become agitated or to develop a
mania while they are taking an SSRI. These medications can decrease libido in both
adolescents and adult. I warn parents about the symptoms of mania, especially if there is a
family history of Bipolar Disorder. If the child has had a manic episode in the past, one might
want to consider a first starting him on a mood stabilizer such as Lithium, or Depakote.

Follow Up and Other Considerations

Some individuals have only one episode of depression, but often depression becomes a
recurrent condition. Thus, one should educate the child and family about the early warning
symptoms of depression so that they can get right back in to the doctor. It is also useful to
discuss the child's particular "early warning signs" with the primary care doctor. Sometimes I
schedule booster sessions in advance and other times, leave the door open for the child or
family to schedule one or two sessions.

The decision about when to stop antidepressant medication can be complex. If the depressive
episodes are recurrent or severe, one may consider longer term maintenance
pharmacotherapy. If the depression was milder, the family wishes the child to be off
medications, or there are side effects, one may consider stopping the medication several
months or a year after the symptoms are gone. If there have been several recurrences, one
might then talk to the patient and family about longer term maintenance. Exercise, a balanced
diet (at least three meals per day) and a regular sleep schedule are desirable. If there is a
seasonal component, a light box or light visor may be helpful.

If there are residual social skills problems, a social skills group through the school or other
agency can help. Scouts and church youth groups can be enormously helpful. If parents and
child consent, I will sometimes involve a scout leader or clergy.

One must treat comorbid psychiatric disorders such as anxiety and ADHD. Since a young
person who has had a depression is more vulnerable to drug abuse, one should start out early
with preventative measures. The primary care doctor can be a partner in monitoring for relapse,
substance abuse and social skills problems during and after the psychiatric treatment.

Carol Watkins, M.D.

Article updated 2004

Back to Top of Page




It’s 1 AM, Do You Know Who’s Treating Your Kids’ Depression?
Did you know he’s depressed? His friends do...

Over 18 million Americans are depressed. As many as 2 million of these are adolescents.
In some cases, the biological tendency toward depression runs in a family. In other
cases, depression is brought on by life stress. In some cases, unfortunately, we never
know.
American families today are busy. Parents, especially those heading a household alone,
may need to work long hours to provide financial support. A parent may be starting to
date again, or may simply be dealing with his or her own depression. A depressed teen
may sense the parent’s stress or preoccupation and feel guilty about burdening the
parent with his own problems. Some parents may try to make the adolescent feel better
by minimizing the problem or they may actually rebuff his request.

Increasingly, adolescents have been seeking each other out when they are confused,
depressed or in trouble. Sometimes, they may form an elaborate network of support for a
depressed or suicidal peer. At its best, this can be a valuable early warning system for
troubled teens. Other times, it may involve sharing antidepressant medications, hiding a
runaway, or avoiding needed psychiatric help. There is also risk for the adolescent
helpers. These helpers may be trying to cope with their own drug abuse or emotional
problems. They often feel a great sense of responsibility toward the depressed
individual. If their friend does commit suicide, the survivors are left with tremendous
guilt.

Parents and adolescents should be aware of the warning signs of depression and
suicidal thoughts. It is important to take the time to communicate with the depressed
individual. Make sure that he or she gets help from responsible adults.

 Possible warning signs of depression

 Sudden changes in behavior

 Aggressive, angry or agitated behavior

 Increased risk-taking

 Changes in appetite or sleep patterns

 Lower self-esteem

 Gives up valued possessions and settles unfinished business.

 Withdraws from friends, activities, and family

 Changes in dress or appearance

 Significant losses or family stress




Recommended reading:

When Nothing Matters Anymore: A Survival Guide for Depressed Teens by Bev Cobain

The Power to Prevent Suicide: A Guide for Teens Helping Teens by Richard Nelson and
Judith Galas



Introduction

Everyone has times they feel sad and don‟t enjoy life. For some people the emotional pain
becomes so severe or prolonged that it becomes a problem. This is depression. Because there
seem to be different patterns of depression that respond to different treatment, psychiatrists
have divided depression into categories.



Types of Depression

         Major Depression is the most severe form of depression. It involves low mood or loss of
enjoyment in most activities for two or more weeks. This is accompanied by such symptoms as
change in sleep and appetite, loss of energy, loss of self-esteem, difficulty concentrating and
preoccupation with death or suicide. In some cases depressed people become irrationally
convinced that something terrible is happening to them, such as poverty or fatal disease. The
depressed person may withdraw from friends and family, and be unable to work. Studies show
that between 6 and 19% of the population will suffer from major depression at some time in
their life. It appears to be a “biological” illness in that the tendency to develop this condition can
run in families, that depression can occur for no apparent reason and when the person has
experienced no significant changes in their life, and that the misery can resolve with medication
treatment alone in some cases.

While symptoms are less intense than in Major Depression, Dysthymic Disorder lasts for
years. In fact the low mood and associated symptoms must be present on most days for at
least two years to qualify for this diagnosis. About 6% of the population will experience this form
of depression.

There are several other important forms of depression. Adjustment Disorder with Depressed
Mood involves a drop in mood in response to a specific stressful circumstance. Bipolar
disorder involves low mood periods similar to Major Depression, but with periods of elevated or
irritable mood as well. Depression can also occur as a biological reaction to certain physical
illnesses (e.g. strokes affecting the left frontal cerebrum, hypothyroidism, pancreatic cancer) or
to chemical substances (e.g. alcohol, methamphetamine, ß-blocking antihypertensive
medications).



Treatment

The optimum treatment depends on the type of depression. Patients with Major Depression
may be treated with medication, psychotherapy, or electro convulsive therapy (ECT). The
choice depends on the symptoms (severity and type), patient preference and history of
treatment response during prior depressive episodes. With more severe forms of Major
Depression it is generally necessary to use either medication or ECT. Specific psychotherapies
can be used along with medication, or as a sole form of treatment in the case of less severe
forms of Major Depression.

Patients with Major Depression are usually treated with medication (about 70% of people
respond well) or ECT (about 80% response rate). Psychotherapy may be an important adjunct
to treatment. Psychotherapy can help the person to decrease the impact of the depressive
symptoms and to sustain hope.

Patients with Dysthymic Disorder have historically been treated with psychotherapy alone. In
recent years however, it has become apparent that more than half (50-60% response rate) of
patients with Dysthymic Disorder will respond to most types of antidepressants[1]. Since the
medications that have been available in the past 10-15 years are relatively non-toxic, it is often
worth trying antidepressant medication with psychotherapy, even when the depression seems
related to psychological factors.

Psychotherapy approaches to dysthymic disorder include Cognitive Psychotherapy,
Interpersonal Psychotherapy, and where conflicts are an important part of the problem,
Psychodynamic Psychotherapy.

Cognitive Psychotherapy is based on the recognition that when people are depressed they
think differently. Pessimism causes the depressed person to expect the worst, and to behave
as if this were a certainty. This results in not trying new things (“it won‟t work” or “I probably
wouldn‟t enjoy it”), in withdrawing from friends (“they will be bored with me”). Cognitive therapy
helps a person to examine the distorted assumptions that go with depression, and that maintain
the person thinking and acting in ways that keep them depressed.

Interpersonal Psychotherapy investigates the ways in which problems with relationships (role
disputes, role transitions, unresolved grief and social deficits) can have a profound impact on
mood and functioning.

Psychodynamic Psychotherapy explores the roots of adult dysfunction in unresolved
childhood conflicts. By doing so it helps explain why the person would choose to do things that
seem harmful to them. It permits a reevaluation of assumptions about oneself and others, so
that the person can deal more effectively with others and themselves.

Antidepressant Medications appear to work by increasing the availability of certain chemicals
in the brain. These chemicals, called neurotransmitters, are necessary for each nerve in the
brain to send messages to other nerves. Several parts of the brain are important in maintaining
our usual range of mood. The information needed to maintain mood is conveyed in part with
chemical signals. In some forms of depression, these chemical signals may be too weak.
Antidepressants can serve to strengthen the signal and help return the low mood to a normal
range. The chemical messengers most commonly affected by these medications are serotonin
(also called 5-hydroxytryptamine or 5HT) and norepinepherine. Often it takes two to four weeks
for depression to respond fully to these medications, although some people may respond in a
matter of days. About 70% of patients with major depression respond to

The first relatively safe and effective medications to treat depression became available over
forty years ago. These were the tricyclics antidepressants, named for the presence of three
rings in their chemical structure. They are just as effective as the most recently marketed
antidepressants. The primary effect of most of the tricyclics antidepressants is to block the
reuptake of norepinepherine and/or serotonin, but in contrast to the „selective‟ medications, their
effects are more diverse. They frequently block effects of other neurotransmitters like acetyl
choline (causing dry mouth, blurry vision, constipation, urinary hesitancy urinary obstruction,
heart palpitations), histamine (causing weight gain and sedation) and the a 1-adrenergic
(norepinepherine) receptor (causing low blood pressure on standing (dizziness, fainting and
heart palpitations) and sexual dysfunction). They can cause heart arrhythmias and seizures
(rarely in usual doses, but more commonly with overdoses). Thus, these medications can be
more dangerous than the more recently introduced antidepressants, if taken as an overdose.
This is of major concern since very severely depressed patients are at greatest risk to attempt
suicide.

Attempts to find medications with fewer and less serious side effects, led to the discovery of
other groups of medication that act more selectively. These include the “selective serotonin
reuptake inhibitors” or SSRI‟s: fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox),
paroxetine (Paxil) and citalopram (Celexa); venlafaxine (Effexor; a selective serotonin and
norepinepherine reuptake inhibitor), trazodone and nefazadone (Desyrel and Serzone,
“serotonin modulators”), mirtazepine (Remeron, a serotonin and norepinepherine enhancer),
and bupropion (Wellbutrin, a norepinepherine enhancer)

Another group of antidepressants is the “monoamine oxidase inhibitors” or MAOI’s. This group
has been around about as long as the tricyclics antidepressants (1950‟s). They can be very
effective antidepressants, and for certain people can be the best treatment. But because of
some potentially dangerous interactions with a number of foods and medications, they are not
usually tried unless other treatments fail. They work by preventing the chemical messengers
(serotonin and norepinepherine) between nerve cells from being destroyed by the enzyme
monoamine oxidase. As with the other antidepressants, this increases the strength of the
chemical signal. The problem with these medications is that there are a number of foods that
contain a chemical, tyramine, which can raise blood pressure if it is not destroyed in the
intestines before it gets into the blood stream. Normally the enzyme monoamine oxidase
(present in the intestines as well as the brain) destroys the tyramine before it can be absorbed.
However if a person takes the MAOI drugs, the enzyme is blocked and the result can be a
dangerous elevation in blood pressure. Many of the foods that need to be avoided are high in
protein and have been partially acted on by bacteria: aged cheese, hard sausages (pepperoni,
salami), pickled herring. Also several varieties of wine and beer (but not distilled liquor) must be
avoided. In addition there are several medications that should not be taken with the MAOI‟s,
including pseudoephedrine (Sudafed), diet pills with phenolpropanolamine (Dexatrim), and most
other antidepressants.

Apart from the dietary and medication interactions, the MAOI‟s have several possible side
effects, including reduced blood pressure, sexual dysfunction, weight gain, sedation, dry mouth
and constipation.

In addition to use as antidepressants these medications are also used to treat panic disorder
and social phobia.

The two most commonly used MAOI‟s are tranylcypromine (Parnate) and phenelzine (Nardil).
  Depression in Parent




Depression can occur at almost any phase of life. However, it can have a special
impact if it occurs in the parent of young children.

Postpartum depression is the best-known form of parental depression. However,
depression can strike men and women at other times too. Depression can make it
difficult for a parent to develop a close, nurturing attachment to a young child. A
depressed parent may be less vigilant about safety issues, or may, on the other
hand, worry excessively about the child’s safety. Depressed individuals are more
likely to feel hopeless and apathetic about parenting, and thus neglect a child. An
irritable, depressed parent might actually abuse a child. t a child. Depression can
sap the parent of the energy necessary to play with an active child. If the
depression leads to alcohol abuse, family problems multiply.

Children of depressed parents are more likely to have behavioral problems,
learning difficulties, and peer problems. They are more likely to become
depressed themselves. Children may have difficulty understanding cause and
effect. Thus, they may blame themselves for the parent’s depression, irritability
and withdrawal.

Why might parents become depressed? Some parents are unprepared for the
hard work involved in raising a child. They may be cut off from their own extended
family and lack good parental role models. Childcare duties may cause the parent
to become increasingly socially isolated. With fewer daily adult contacts, the
parent has fewer voices to counter his or her depressive thoughts. Parents who
work outside the home may also experience stress. The dual demands of work
and home may lead to sleep deprivation and exhaustion, leaving him more
vulnerable to depression and medical illness.

Some adults have unresolved issues from their own childhood. They may have
pushed these memories “under the rug.” Having a child or adolescent may bring
back vivid memories from when the parent was that age.

It is important for parents to seek treatment for their depression. Once the
depression lifts, they will be able to enjoy their child, bond more closely and
empathize with the child’s emotions. The healing process may involve reaching
out to friends and family for support.

If the parent enters psychotherapy, it may give him a second chance to resolve
issues from his own childhood. The parent may gain a greater understanding of
the child’s internal experiences when he examines his own. A parent who has
worked through a depression may have special empathy for the child’s sad or
anxious moods.

More articles on depression in children and adults

				
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