My daughter is depressed

English

Worldwide every year 800,000 to 1.2 million people commit suicide. In the Netherlands, with a population of over 17 million, more than 1,800 people die by suicide every year and 94,000 people with suicidal thoughts attempt to take their lives. Despite these high rates and the damage it does to those involved and to society, talking about suicide is still considered a taboo. People with suicidal thoughts often feel isolated. This is partly, because the health care professionals they visit are unable to address the issues of despair and suicidality. In order to promote suicide prevention in healthcare and beyond, 113 provides a range of online services. These services can be used anonymously and free of charge 24/7. This allows people with suicidal thoughts find or regain hope, get help and find adaptive ways to cope with despair and psychological pain. In addition, 113 aims at empowering, teaching and training health care professionals, gatekeepers throughout society, relatives and friends in order for them to overcome their reluctance to address suicidal thoughts and behaviour for those in need.

Who we are

113 Suicide Prevention is the national Dutch suicide prevention centre, financed mainly by the Dutch Ministry of Health, Welfare and Sport (Ministerie van VWS). Our organization has been active as an independent care provider since September 2009. We employ psychologists and psychiatrists and a large group of fully trained volunteers who allow us provide round-the-clock confidential support through chats and phone calls. 113 works in close cooperation with the mental health institutes’ crisis centres. Together, these professionals are available 24 hours a day, 7 days a week across the Netherlands for crisis dialogues and psychological treatments.

Mental health services

Our mental health services include:

  • Crisis chat (a direct opportunity to talk online to a trained volunteer)
  • Crisis telephone (a direct opportunity to talk to a trained volunteer by phone and, if necessary, to a professional)
  • Chat therapy (a maximum of 8 online chat dialogues with a professional)
  • Self-help course (an independent online course aimed at reducing suicidal tendencies)
  • Self-tests (questionnaires to fill in and to offer an indication of the severity of your troubles and symptoms (an anxiety and depression test and a test that measures suicidal tendencies)
  • Consultation by telephone for other professionals, next of kin or friends about somebody in need (the opportunity to pose a brief question to a professional in a session lasting a maximum of ten minutes)

Training academy

In addition, we support clients with our training services aimed at both professionals working in mental health care (GGZ professionals) and people who are facing suicide in their professional practice or personal environment. In our gatekeepers’ training programme our clients learn how to identify signs of suicidal thoughts, to address those and how to refer to professional help.

Center of expertise

Besides our mental health services, 113 acts as a change agent and centre of expertise: it leads the National Suicide Prevention Agenda (Landelijke Agenda Suïcide Preventie) and establishes Suicide Prevention Action NETworks (SUPRANET Care, SUPRAnEt Community). Activities in these domains include:

  • The development and dissemination of training opportunities for medical staff, other professionals and gatekeepers in society;
  • Tracking the implementation and sharing of evidence-based best practice of suicide prevention within large healthcare institutions, using standardized monitoring instruments and methods;
  • Implementation of multilevel multimodal suicide prevention measures in 8 regions, reaching 2.5 million inhabitants, in line with the European Alliance Against Depression (Optimizing Suicide Prevention Interventions OSPI);
  • Data-driven quality and safety improvement projects in a network currently numbering 14 mental health hospitals.

International orientation

113 has a strong international orientation through participation in the European Alliance Against Suicide and our role in the International Zero Suicide Movement.
We are continuously developing our work by researching the effectiveness and reach of our menthal health services together with our partners, the VU University of Amsterdam and the mental health institution GGZ inGeest. Together we have initiated SURE-NL, a scientific consortium aimed at lifesaving suicide research. 113 has been invited to contribute to major scientific conferences worldwide (Rome, Beijing, Tel Aviv, Boston, Atlanta, London and Ghent).

Leaflet 113 Suicide Prevention

Depression

Therapists treat depression and other mood disorders with talk therapy, sometimes medicine, or both. Parent counseling is often part of the treatment, too. It focuses on ways parents can best support and respond to a kid or teen going through depression.

More Ways to Help

Treatment with a therapist is important. But you play an important role, too. At home, these simple but powerful things can help your child deal with depression.

Be sure your child eats nutritious foods, gets enough sleep, and gets daily physical activity. These have positive effects on mood.

Enjoy time together. Spend time with your child doing things you both can enjoy. Go for a walk, play a game, cook, make a craft, watch a funny movie. Gently encouraging positive emotions and moods (such as enjoyment, relaxation, amusement, and pleasure) can slowly help to overcome the depressed moods that are part of depression.

Be patient and kind. When depression causes kids and teens to act grumpy and irritable, it’s easy for parents to become frustrated or angry. Remind yourself that these moods are part of depression, not intentional disrespect. Avoid arguing back or using harsh words. Try to stay patient and understanding. A positive relationship with a parent helps strengthen a child’s resilience against depression.

Reviewed by: D’Arcy Lyness, PhD Date reviewed: August 2016

Depression in Children

What is depression?

Depression is a mental illness marked by persistent feelings of sadness, irritability, loss of interest in activities, feelings of hopelessness and worthlessness, and sometimes, thoughts of suicide. It affects the way one feels, thinks, and acts. Often, people who are depressed also experience changes in their sleeping and eating habits and have trouble concentrating. A diagnosis of depression is made when symptoms persist for two weeks or longer and interfere with a person’s ability to function.

Can children suffer from depression?

Yes. Childhood depression is different from the normal “blues” and everyday emotions that occur as a child develops. When symptoms persist and interfere with social activities, interests, schoolwork, and family life, however, a child may have depression.

Depression is not a passing mood, nor is it a condition that will go away without proper treatment. Depression is often not diagnosed and treated because the symptoms are passed off as normal emotional and psychological changes that occur during growth. Keep in mind that while depression is a serious illness, it also is a treatable one. Parents should speak with their child’s pediatrician or contact a mental health professional if they have any concerns about changes in a child’s mood or behavior.

How common is depression in children?

The National Institute of Mental Health estimates that at least 3.3% of children 13 to 18 years old have had episodes of severe depression. The American Academy of Adolescent Psychiatry estimates this number to be 5%. Suicide is the third leading cause of death in young people between the ages of 10 and 24.

What causes depression in children?

As in adults, depression in children can be caused by any combination of factors, such as:

  • Physical illness (such as diabetes or epilepsy)
  • Stressful life events
  • Environment (including family problems)
  • Family history (others in the family have depression)
  • Alcohol or drug use

How can I tell if my child is depressed?

Every child with depression may present with a unique set of symptoms. Signs and symptoms of depression in children include:

  • Irritability, anger, or being “on edge”
  • Persistent feelings of sadness, hopelessness
  • Withdrawal from previously enjoyed activities as well as from friends and family
  • Increased sensitivity to rejection or criticism
  • Changes in appetite (either increased or decreased)
  • Changes in sleep (sleeplessness or too much sleep)
  • Crying or temper tantrums
  • Difficulty concentrating and focusing
  • Fatigue (tiredness) and low energy
  • Physical complaints (such as stomach aches, headaches) that do not respond to treatment
  • Reduced ability to function during activities at home or with friends, in school, extracurricular activities, and in other hobbies or interests
  • Feelings of worthlessness or guilt
  • Thoughts or talk of death or suicide

Not all depressed children will have all of these symptoms. In fact, most will have different symptoms at different times and in different settings. Although some children may continue to function reasonably well in structured environments, most kids with significant depression will suffer a noticeable change in social activities, loss of interest in school and poor academic performance, or a change in appearance. Experimentation with drugs or alcohol may also be a sign of an underlying mental illness.

Although relatively rare in youths under 12, young children do attempt suicide, and may do so impulsively when they are anxious, angry, or upset. Girls are more likely to attempt suicide, but boys are more likely to actually succeed in killing themselves when attempting suicide. Children with a family history of violence, alcohol abuse, or physical or sexual abuse are at greater risk for suicide, as are those with symptoms of depression. Children are also at risk when they have access to firearms or medications at home.

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Childhood Depression

Rates of childhood depression have been rising in the last several years. Yet, information and awareness about childhood depression has not caught on at the same rate. Millions of people across the world wonder and doubt if children can get depressed. Many well-intentioned adults still believe that children ‘can’t get depressed. They are so young- what do they have to be depressed about? When we were that age, we were just happy’. Alongside misunderstanding is stigma and the idea that mental illness is a taboo subject.

What we now know:

  • Childhood depression is a real, distinct clinical entity.
  • It is a serious health condition, which if left untreated, increases risk of future, prolonged and more severe depressive episodes. Untreated depression in childhood and adolescence can pose risk of suicide.
  • Depression often has biological, psychological and social underpinnings. An individualized treatment plan that explores and addresses each of these aspects, works best.
  • Effective treatment options for childhood and teen depression have been widely tested, proven and established, through several scientific studies over the years.
  • Childhood depression can be hidden and therefore, easily missed. Timely recognition and treatment can be life-changing and life-saving.
  • The barriers surrounding mental health stigma are beginning to give way due to powerful social movements and discussions that address realities of mental health.

Who is Affected by Depression in Childhood or Teenage?

Depression can affect anyone. However, children or teens who have immediate family members with a history of depression or other mood disorders (such as bipolar disorder) are more likely to suffer from depression, often due to a genetic predisposition. Predisposition implies greater likelihood; it does not mean that the child or teen will necessarily experience depression.

Children with chronic or severe medical conditions are at a greater risk of suffering from depression.

Common Signs of Depression in Childhood or Adolescence

Depression in childhood/adolescence can manifest somewhat differently than it does in adults. Irritability and/or anger are more common signs of depression in children and teens.

When depressed, younger children are more likely to have physical or bodily symptoms, such as aches or pains, restlessness, distress during separation from parents, as they may not have the emotional attunement and/or expressive abilities to talk about their emotions.

Other signs of depression in children and teens, can be:

  • Loss of interest in usual fun activities
  • Withdrawal from social or usual pleasurable activities
  • Difficulties with concentration
  • Running away from home or talking about running away from home
  • Talking about death or dying, giving away (or talking about giving away) favorite possessions, writing goodbye letters
  • Sleep increase (or decrease)
  • Appetite/weight changes (more likely an increase, in depressed teens)
  • Occasionally, new or recent onset agitation or aggression
  • Comments indicating hopelessness or low self-worth

Not all of the above-mentioned symptoms have to be present for a diagnosis of depression. Symptoms usually occur on most days, for at least 2 weeks, in order to meet criteria for depression. When seeing a professional to explore a diagnosis, you can utilize online health resources to prepare meaningful questions to ask a doctor in order to facilitate productive conversation for treatment.

Ruling Out Medical Conditions First

Psychiatric disorders are diagnosis of exclusion, which means that only if the symptoms are unexplained by medical conditions, or effect of substances or other non-psychiatric causes, would the cause of symptoms be deemed to be due to a primary psychiatric disorder.

Before arriving to the diagnosis of depression, a child or teen who is suspected to be depressed, must undergo a comprehensive medical evaluation to rule out any underlying medical condition which could be manifesting as or resulting in depression. For example, hypothyroidism (depressive symptoms, weight gain, low energy, cognitive difficulties, constipation). Even conditions such as undiagnosed anemia can mimic depression, due to accompanying fatigue/low energy. Vitamin D deficiency, common in cold climates, increases risk of depressive symptoms and fatigue. The good news is that these conditions have effective treatments, and treatment of the underlying medical condition in a timely manner should resolve depressive symptoms.

Ruling Out Other Psychiatric Conditions

Rule out undiagnosed/untreated ADHD (attention Deficit Hyperactivity Disorder), anxiety disorders or other psychiatric conditions, which when left untreated, can result in depressive symptoms due to the impairment in functioning from ADHD or anxiety disorder itself.

Treatment

Why Treat?
Depression is associated with visible brain changes seen on functional brain MRI studies of depressed individuals. Treatment, for example, psychotherapy has been shown to confer long term benefit and neural changes in the brain.

How Do I know My Child Needs Treatment?

In addition to an overall assessment, your child’s pediatrician may administer rating scales and other forms of assessment to determine the degree of depression and may refer you to a psychiatrist or a psychotherapist.

We know a child/teen needs treatment for depression when their school, social, and/or home functioning is significantly affected by depressive symptoms, on a frequent basis.

If your child/teen is feeling suicidal and/or having thoughts/urges to hurt themselves, call 911 or take your child/teen to the nearest ER.

What Kind of Treatment?

For mild to moderate depression, CBT (Cognitive Behavioral Therapy) is the typical first-line treatment of choice for children and teens. There can be exceptions to this, depending on the specific clinical condition, age and circumstance of the child. For children younger than 10, other modalities of psychotherapy such as play therapy, psychodynamic psychotherapy, and behavior therapy may be utilized.

For moderate to severe depression, evidence-based guidelines recommend a combination of CBT and antidepressant medications (typically SSRI medications, also known as Selective Serotonin Re-Uptake Inhibitors).

SSRI Use for Depression in Children

  • SSRIs and other antidepressants have a black box warning from FDA about risk of increase in suicidal thoughts and behavior with use, particularly in the early phase of treatment. Studies did not show completed suicides.
  • After this warning came out in 2004, antidepressant prescription rates dropped, and suicide rates climbed up.
  • Close monitoring during dose initiation, titration and dose changes helps to reduce this risk
  • Antidepressant medication use in children and adolescents is preceded by a weighing of benefits and risks of use versus risks of untreated depression.
  • Fluoxetine and Escitalopram are FDA approved for treatment of depression in children and teens.
  • Studies involving paroxetine (another SSRI) have shown a higher profile of side effects with its use in children, and therefore, may not be recommended for children and teens.
  • Studies show a higher likelihood of an individual responding to an SSRI that an immediate family member benefitted from (however, this is a likelihood, not necessary that it will happen in each situation)

If depressive symptoms are secondary to other conditions, such as untreated ADHD or anxiety disorders, adequate treatment of those disorders is essential and will usually resolve the depressive symptoms. However, in certain situations, specific antidepressant medications and/or psychotherapy targeted towards depression may be needed in addition. One might note that if trials of two or more antidepressants are not effective, or if a child/teen is sensitive to medications in general, there are additional avenues that can be explored. One plausible route for consideration is genetic testing that combines personal genetic data with medication information to achieve the desired remedy.

Your child’s pediatrician/psychiatrist, therapist, together with you, may also explore for any bullying, trauma, and will try to understand your child/teen’s inner life and look further for any school, social, family or other stressors that may be contributing to, or exacerbating/perpetuating the depressive condition. If family stressors are significantly contributing to your child’s depression, your doctor may recommend family therapy in addition. With your permission, the doctor/therapist may coordinate with your child’s school to share recommendations to optimize your child’s school functioning and emotional well-being at school.

Overcoming Mental Health Stigma

In 1999 the United States Surgeon General labeled stigma as quite possibly the biggest barrier to mental health care. Stigma manifests as misguided stereotypes and negative attitudes or beliefs towards those with mental illness. Research shows that stigma and embarrassment were the top reasons why people with mental illness did not engage in medication adherence, such as self-care, therapy and medication compliance. As of late, there has been an increase in available resources and tools to overcome stigma for children and teens, as well as their caregivers. Allies such as Bring Change to Mind, an organization focused on encouraging dialogue about mental health, as well as raising awareness through education, offers high-school and college programs that foster a culture of peer support within schools.

A Word About Substance Use and Depression

Sadly, substance use among teens is becoming rampant across the country, even in reputed school districts, and thus, needs to be addressed when exploring and treating depression.

Marijuana use is particularly common among teens. Marijuana is considered to be a ‘gateway drug’ and can lead to ‘amotivational syndrome’. This syndrome manifests as low motivation to do things, and in conjunction with marijuana related ‘munchies’ can mimic a primary depressive disorder. In many cases, a teen may be ‘self-medicating’ for untreated or undiagnosed depressive or anxiety symptoms through substance use. Use or withdrawal from other substances can cause depressive, mood symptoms as well.

Proper and timely treatment can be very effective in resolving depressive symptoms and in reducing risk of relapse. Please consult your child’s pediatrician or health care provider if you suspect your child/teen may be suffering from a medical or a psychiatric condition.

Note: This article is for informational purposes only and is not intended to provide medical or psychiatric advice or recommendations, or diagnostic or treatment opinion. This is not a complete review or description of this subject. If you suspect a medical or psychiatric condition, please consult a health care provider. All decisions regarding an individual’s care must be made in consultation with your healthcare provider, considering the individuals’ unique condition. If you or someone you know is struggling, please contact the 24×7, confidential National Hotline at 1-800-273-8255 or use the crisis text line by texting HOME to 741741 in the US, or go to http://www.suicide.org/international-suicide-hotlines.html for the suicide hotline number for your country.

About the author:

Richa Bhatia, MD, FAPA is a Child, Adolescent and Adult psychiatrist, dual Board certified in Child, Adolescent and General Psychiatry. She is the author of 2 books: ‘Demystifying Psychiatric Conditions and Treatments’ and ‘65 Answers about Psychiatric Conditions’. Previously, she served as a faculty member in the departments of psychiatry at Harvard Medical School and Geisel School of Medicine at Dartmouth. She serves as an Associate Editor for Current Psychiatry, Section Editor for Current Opinion in Psychiatry and is on the editorial board of several other psychiatry journals. She is an expert contributor for Psychology Today and Thrive Global. Some of her interests are childhood depressive and anxiety disorders, the interface between medical and psychiatric conditions, differential diagnosis, compassion and bullying prevention. She is an active member of the Child and Adolescent Psychiatry Section of the World Psychiatric Association (WPA), the American Psychiatric Association and the Anxiety and Depression Association of America.

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