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Depression, Adolescent

Basics

  • Primary mood disorder marked by sadness and/or irritability, impaired functioning.
  • Incidence: 6–12% adolescents; female > male (2:1).
  • Cumulative risk during adolescence 5–20%.

Etiology and Pathophysiology

  • Neurobiologic factors: HPA axis overactivity, serotonergic and dopaminergic dysfunction.
  • External contributors: substance use, adverse childhood events, poor social support.
  • Genetics: 3–4× increased risk if parent has depression; childhood anxiety often precedes adolescent depression.

Risk Factors

  • Prior depression episodes
  • Insomnia, anxiety, ADHD, body dysmorphic disorder, chronic illness, learning disabilities
  • Female gender, increased screen time
  • Stressors: peer problems, bereavement, academic difficulty, abuse, tobacco use, low SES
  • LGBTQ identification

Diagnosis

History

  • Symptoms present ≥2 weeks; ≥5 symptoms including depressed/irritable mood or anhedonia:
  • Sadness or irritability
  • Loss of interest or pleasure
  • Unintentional >5% weight loss in 1 month
  • Insomnia or hypersomnia
  • Psychomotor changes
  • Fatigue
  • Feelings of worthlessness or guilt
  • Impaired concentration
  • Recurrent suicidal ideation or plan
  • Symptoms cause significant functional impairment.
  • Exclude substance-induced or other medical/psychiatric causes.

Physical Exam

  • Assess concentration, speech, affect, psychomotor activity.
  • Screen for self-injury signs and abuse.

Differential Diagnosis

  • Normal bereavement
  • Bipolar disorder
  • Adjustment disorder
  • Medical causes: thyroid disorders, anemia, vitamin deficiencies, infections
  • PTSD, eating disorders, ADHD, anxiety, sleep disorders

Diagnostic Tests

  • Labs to rule out medical causes: CBC, TSH, glucose, B12, folate, mono spot, urine drug screen.
  • Diagnosis primarily by clinical interview with caregiver/teacher input.
  • Screening tools:
  • Beck Depression Inventory II (ages 13–18)
  • Child Depression Inventory 2 (ages 7–17)
  • CES-DC (ages 6–17)
  • PHQ-9 (ages 11–17)
  • Assess suicidality using structured tools.

Treatment

General Measures

  • Education on depression and its impact.
  • Psychotherapy and/or pharmacotherapy based on severity, comorbidities, and social context.
  • Incorporate family and school environments in management.
  • Safety planning if suicidality risk exists.

Medications

  • First Line:
  • Fluoxetine (>8 years): start 10 mg/day, effective 10–60 mg/day.
  • Escitalopram (>12 years): start 5 mg/day, effective 10–20 mg/day.
  • Citalopram, sertraline also FDA-approved (>12 years).
  • Dose titration every 1–2 weeks as tolerated.
  • Monitor for headaches, GI upset, insomnia, agitation, suicidal thoughts.
  • Black box warning for increased suicidality risk; close follow-up recommended.
  • Adolescents may require twice-daily dosing to mitigate withdrawal.
  • Paroxetine and TCAs not recommended.

Referral

  • For complex or treatment-resistant depression, child psychiatry referral advised.

Surgery/Other

  • Electroconvulsive therapy effective in refractory cases.

Complementary Medicine

  • Physical exercise and light therapy may have mild to moderate benefits.
  • Insufficient evidence for St. John’s wort, acupuncture, S-adenosylmethionine, 5-HTP.

Inpatient Care

  • Indicated for severe depression, psychosis, suicidality, or homicidality.

Ongoing Care

  • Continue antidepressants 6–12 months post symptom resolution.
  • Monitor monthly for 6 months, then regularly for 18 months.
  • Track symptoms and functioning in home, school, peer contexts.
  • Reassess if no improvement after 6–8 weeks.

Prognosis

  • 60–90% remission within 1 year.
  • Adolescent depression predicts adult mental health challenges, psychosocial difficulties.

Complications

  • Treatment-induced mania/aggression.
  • School failure or refusal.
  • One-third with suicidal ideation attempt suicide.

ICD10 Codes:
- F32.9 Major depressive disorder, single episode, unspecified
- F33.9 Major depressive disorder, recurrent, unspecified
- F32.8 Other recurrent depressive disorders

Clinical Pearls:
- Adolescent depression often underdiagnosed; irritability and anhedonia common presentations.
- Fluoxetine is the most studied and FDA-approved for adolescents.
- Escitalopram, citalopram, and sertraline are additional FDA-approved SSRIs.
- CBT combined with fluoxetine shows high efficacy.
- Avoid paroxetine and TCAs in adolescents.
- Close monitoring for suicidality essential, especially during first treatment month.