Depression in Adolescents

Introduction
Depression is a complex construct, applied to individuals with a particular set of symptoms among which the essential ingredients are a depressed mood and a loss of interest. Depression is a state of low mood and aversion to activity that can have a negative effect on a person's thoughts, behavior, feelings, world view and physical wellbeing. Depressed people may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, hurt or restless. They may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, have problems concentrating, remembering details, or making decisions and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may also be present.

Classification of Depressive Disorders: Historical Background From Hippocrates to Kraepelin

Descriptions of depression and depression-related mental disorders date back to antiquity (Summerian and Egyptian documents date back to 2600 BC). However, it was Hippocrates and his disciples who first studied these conditions systematically and introduced the term melancholia to describe the symptoms and to provide a physiological explanation of their origin. The Hippocratic School attempted to link the balance of the postulated four humors (blood, yellow bile, black bile and phlegm) with the temperament and personality, and the latter two with the propensity to develop one of the four diseases (mania, melancholia, phrenitis and paranoia). The term melancholia survived as the only specified of morbid mood and disposition until Kraepelin , at the end of the 19th century, introduced the term manic-depression to separate nosologically mood disorders from dementia praecox, known after Bleuler as schizophrenia.

From Kraepelin to DSM-IV and ICD-10

The eighth revision of the WHO International Classification of Diseases, Injuries and Causes of Death (ICD-8) signaled the beginning of a systematic effort at an international level to develop a unified system of diagnosis and classification of mental disorders. Despite improvements brought about in the ninth revision (ICD-9), both these WHO systems limited their diagnostic guidelines to narrative descriptions that did not particularly enhance the diagnostic reliability of mental disorders.

This was also true for the first two editions of the American Psychiatric Associations (APA) Diagnostic and Statistical Manual of Mental Disorders, which in addition to narrative presentation of symptoms attempted to associate clinical features with psychopathological mechanisms. The advent of DSM-III in 1980 marked the contemporary era in diagnosis and classifications of mental disorders. An additional feature of the latest edition (DSM-IV) is that it was initially designed to be compatible with the WHOs tenth revision (ICD-10) of the Classification of Mental and Behavioral Disorders.

Comparison of ICD-10 with DSM-IV

ICD-10 and DSM-IV are basically similar in their orientation, and despite their differences, mainly in terminology, may be used interchangeably in clinical practice. They converge on the following major features: (a) (b) (c) (d) (e) The previously dispersed depressive disorders are grouped together under a common name signifying a unified syndromal entity; The term affective disorders is replaced by the term mood disorders, thus narrowing the depressions boundaries by not subsuming anxiety disorders under the same roof; The diagnostic criteria are symptom-based, descriptive and not explanatory; Symptom severity and recurrence are used as subtyping and specifying criteria. Dysthymia is classified as a separate entity within the general frame of depressive disorders.

Clinical Presentation of Depression

Depression signifies an affective experience (mood state), a complaint (reported as symptom) as well as a syndrome defined by operational criteria. As an affective experience of sadness, it is common to all humans; as a symptom, it is present in several mental and physical illnesses and, as a syndrome, it is associated with specific mental and physical disorders. The prototype of the syndromal entity of depressive disorders is the Depressive Episode (DE) in ICD-10 and the corresponding Major Depressive episode (MD) in DSM-IV. In both systems, it serves as the qualifying yardstick for all the other forms of depression.

Depressive Episode Major Depression

Both DE and MD are specified according to their severity (mild, moderate, severe) and course (single or recurrent). The symptom criteria for the DE according to ICD-10 are: -General Criteria: (a) The depressive episode should last for at least 2 weeks. (b) Not attributable to psychoactive substance use or to any organic mental disorder. -Typical Symptoms: (a) Loss of interest or pleasure in activities that are normally pleasurable. (b) Decreased energy or increased fatigability. -Additional Symptoms: (a) Unreasonable feelings of self-reproach or excessive and inappropriate guilt. (b) Recurrent thoughts of death or suicide, or any suicidal behavior. There is no one single pathognomonic symptom that in it self would identify DE/MD depression and would allow its monothetic classification.

Dysthymia
Dysthymia was introduced as a new diagnostic category of mood disorder by DSM-III and was established in subsequent editions of the DSM and in ICD-10. It includes several depressive conditions that share chronicity as a common characteristic but otherwise are rather heterogeneous with regard to their clinical presentation, neurobiological correlates and treatment response. Most of the patients currently subsumed under the term dystymia were described in the past as having depressive neurosis, depressive personality, and characterological depression. The patients assigned to this category do not fulfill the criteria for recurrent depression but in addition to depressive mood need to have at least two of the following: poor appetite or overeating, insomnia and hypersomnia, low energy, low self-esteem, poor concentration, inability to decide and hopelessness. The symptoms have to at least

lat for 2 years, usually without remissions or with occasional free intervals of a short duration.

Cyclothymia
Cyclothymia is characterized by persistent instability of mood and involves symptoms of depression and elation, which are insufficient in severity and pervasiveness to meet the full criteria of either manic or depressive episodes. The pursuit a chronic course for at least 2 years with or without normothymic intervals, which if present according to DSM-IV should not exceed the 2-month duration. Cyclothymia, as a distinct entity separate from MD, does not correspond to Schneiders concept, which was synonymous to bipoloar disorder. The current concept, although still ill-defined, brings it closer to a subaffective chronic state of mood fluctuations that is linked to personality disorders.

Postnatal Depressive Disorders

These disorders present in three forms. The first is a transient anxiety-depressive state known as postpartum blues that occurs a few days after delivery, peaks within 10 days and subsides usually within 3 weeks after delivery. About half of the mothers experience the blues in various degrees. The symptoms are mild, not necessitating medical attention. The second form occurs in almost 10-15% of mothers, as a rule within the first month after delivery. The symptoms do not essentially differ from the moderate and severe nonpsychotic DE/MD. The third, known as postpartum depression with psychotic features, occurs in about one out of 1000 mothers. In this form of postnatal depression, the first month after delivery is characterized, in addition to DE/MD symptomatology, by psychotic features among which are delusional thoughts, mainly concerning the newborn, in association with severe crying spells, guilt feelings, suicidal ideation and occasionally with hallucinatory experiences. Differential diagnosis is necessary from thyroid dysfunction and drug-induced syndromes.

Depressive Disorders in Adolescents

Until recently it was widely believed that depressive disorders were rare in young people. Over the past 20 years, however there has been a substantial change in the ways in which mood disturbance among the young has been conceptualized. The use of structured personal interviews has shown that depressive syndromes resembling adult depressive disorders can and do occur among both prepubertal children and adolescents.

Clinical Picture and Differential Diagnosis Diagnosis of Depressive Disorder

Defining the boundaries between extremes of normal behavior and psychopathology is a dilemma that pervades all of psychiatry. It is especially problematic to establish the limits of depressive disorder in young people, because of the cognitive and physical changes that take place during this time. Adolescents tend to feel things particularly deeply, and marked mood swings are common during teens. It can be difficult to distinguish these intense emotional reactions from depressive disorders. It is only by adolescence that young people will regularly describe themselves in terms of psychological characteristics. Assessment of young people who present with symptoms of depression must therefore begin with the basic question of diagnosis. This will mean interviewing the adolescent alone. It is not enough to rely on accounts obtained from the parents since they may not notice depression in their children, and may not even be aware of their suicidal attempts. It is now common practice to obtain information from several sources. Accounts from adolescents and parents are usually supplemented by information from other sources, particularly teachers, peers and direct observations. Standardized diagnostic systems such as DSM-IV and structured psychiatric interviews can help in deciding whether the patient has serious depressive symptomalogy that requires treatment. Unfortunately, such diagnostic systems tend to be overinclusive in this age group and many dysphoric adolescents who meet this criteria for major depression remit within a few weeks. Probably the best single indicator of whether or not a young person has a serious depression is the duration of the problem. Polysymptomatic depressive states that persist for more than 6 weeks usually require intervention. A number of factors need to be considered in selecting an instrument to assess depression among the young. In clinical settings, self-report questionnaires provide a convenient way of screening for symptoms that are not part of presenting complaint, and may be useful for measuring treatment response. They are especially helpful in monitoring subjective feelings. In research settings, questionnaires have been used both as a primary source of data and as a screening instrument to select subjects for further in-depth interviews. Unfortunately, many depressive questionnaires have low specificity for depressive disorders. This means that if they are used as screens, then many young people who have high scores on the screening questionnaire will turn out to have a depressive disorder at interview. These problems in making the clinical diagnosis of depression have led to much interest in the use of psychobiological measures as markers of depressive disorder. Probably the best known of these is the dexamethasone suppression test (DST).

Aetiology

The aetiology of child and adolescent depressive disorders is likely to be multifactorial, including both genetic and environmental factors. Genetic factors account for a substantial amount of the variance in liability to bipolar illness in adults, but probably play a less substantial, though still signicant, part in unipolar depressive conditions. Interest in the genetics of depressive disorders arising in young people has been stimulated by data from several sources. First, it seems that, among adult samples, earlier age of onset is associated with an increased familial loading for depression. Second, the children of depressed parents have greater than expected rates of depression. Third, there are high rates of affective disorders among the rst-degree relatives of depressed adolescents probands. Moreover, there is some specicity in this linkage, to the extent that the risk applies mainly to affective disturbances as opposed to nonaffective disorders.

Principles of Treatment
Many of the general principles of treatment follow from the description of the depressed young persons difficulties. Comorbidity is frequent, there are many complications and there is a high risk of relapse. Other types of adversity are part of the cause and may need intervention in their own right. The course is determined by more than just the presence and severity of depression. Therefore, attention must be paid to biological, familial, educational and peer contributions. A treatment programme therefore has multiple aims: to reduce depression, to treat comorbid disorders, to promote social and emotional adjustment, to improve self-esteem, to retrieve family distress and to prevent relapse.

Initial Management
The initial management of depressed young people depends greatly on the nature of the problems identified during assessment procedure. The assessment may indicate that the reaction of adolescent is appropriate for the situation. In such a case, and if the depression is mild, a sensible approach can consist of meetings, sympathetic discussions with the adolescent and the parents, and encouraging support. These simple interventions, especially if combined with measures to alleviate stress, are often followed by an improvement in mood. In other cases, particularly those with severe depression or suicidal thinking, a more focused form of treatment is indicated. It is important that the clinician considers a number of key questions early on in the management of depressed young people. The rst question is whether the depression is severe enough to warrant admission to hospital. Indications for admission of depressed children are similar to those applicable to their adult counterparts, and include severe suicidality, psychotic symptoms or refusal to eat or drink. A related question is whether the child should remain at school. When the disorder is mild, school can be a valuable distraction from depressive thinking. When the disorder is more severe, symptoms such as poor concentration and motor retardation may add to feelings of hopelessness. It is

quite common in such cases that ensuring that the child obtains tuition in the home, or perhaps in a sheltered school, improves mood considerably

Individual and Group Psychological Therapies

Many different individual or group psychosocial interventions have been used with depressed teenagers, including cognitive therapy, psychotherapy, art therapy and drama therapy. Depression is a problem with such pervasive features that one can find abnormalities in almost any domain to justify virtually any intervention. This review therefore uses several inclusions criteria to select from the huge array of interventions. The rst is whether there is a theory about the mechanisms of disorder and about how treatment reduces dysfunction. The second is whether there has been basic research on these mechanisms independent of treatment outcome studies. The third criterion is whether the treatment has been, or is being, evaluated in randomized controlled trials. Two individual or group psychological treatments are relatively well developed in respect of these criteria: cognitive-behavior therapy and interpersonal psychotherapy.

Individual and Group Cognitive-Behavioral Therapies

According to cognitive theory, depression is not simply triggered by adversity but rather by the perception and processing of adverse events. Research has shown that depressed children often have low self-esteem and a variety of cognitive distortions such as selectively attending to negative features of an event. In addition, depressed children are more likely than the non-depressed to develop negative attributions. For example, Curry and Craighead found that adolescents with greater depression attributed the cause of positive events to unstable external causes. Depressed children also have low perceived academic and social competence. Cognitive-behavioral treatment (CBT) programs were developed to address the cognitive distortions and decits identied in depressed children. Many varieties of CBT exist for adolescence depression, but they all have the following common characteristics. First, the child is the focus of treatment (although most CBT programs involve parents). Second, therapists play an active role in treatment; the child and therapist collaborate to solve problems. Third, the therapist teaches the child to monitor and keep a record of thoughts and behavior; there is much emphasis on diary-keeping and on homework assignments. Fourth, treatment usually combines several different procedures, including behavioral techniques (such as activity scheduling) and cognitive strategies (such as cognitive restructuring). Treatment in the school setting allows easy access. This is important because epidemiological studies suggest that only a minority of depressed young people come to mental health services for treatment. It is also easier to integrate psychological treatment with work carried out by other professionals, such as teachers. A potential disadvantage is that it may be difficult to maintain privacy. Moreover, school-based group

interventions may not be suitable for young people with severe problems, such as children who repeatedly harm themselves. Extant research on CBT also has several limitations. First, it is based on samples with mild or moderately severe depression. CBT may not be effective in severely depressed adolescents. Second, much of the published research has compared CBT with inactive conditions such as remaining on a waiting list or psychological placebo. The high rate of spontaneous remission in teenage depression means that it is important to demonstrate that CBT is better than no treatment. Third, we also need to know how CBT compares with other recognized forms of intervention, such as medication. Fourth, it is unclear whether cognitive or behavioral processes correlate with a better outcome. The therapeutic basis for change is therefore uncertain. Finally, it is not known whether CBT has lasting benets for depressed adolescents. The available evidence suggests that to avoid relapse it may be necessary for some cases to have ongoing treatment or booster sessions. Such sessions are now part of many treatment programs. Even so, CBT is a highly promising treatment whose efficacy has been demonstrated in several independent studies.

Interpersonal Psychotherapy
Interpersonal psychotherapy (IPT) is based on the premise that depression occurs in the context of interpersonal relationships. It derives from a number of theoretical and empirical sources, the most prominent theoretical source being the work of Adolf Meyer, whose psychobiological approach to understanding psychiatric disorders emphasized the importance of the environment. The empirical basis for treating teenage depression with IPT comes from research showing a strong association between depression and problems with relationships. Whilst IPT develops from an interpersonal view of depression, it does not assume that interpersonal problems cause depression. The interpersonal context can contribute to the alleviation of the adolescents depressive symptoms, regardless of the personality organization or biological vulnerability of the individual. IPT is a brief time-limited therapy. The two main goals are to identify and treat, rst, the depressive symptoms and second, the problems associated with the onset of depression. Interpersonal psychotherapy is a promising but as yet untested treatment for depression in young people. Its promise stems both from the evidence that it is an effective treatment for depression in adults and from its underlying rationale.

Family Therapy
There has been a large amount of research on the families of depressed adolescents. There is now strong evidence of an association between depression in teenagers and problems of family members, including mental illness and dysfunctional family relationships. This association is likely to reect environmental mechanisms as well as genetic processes. Family factors associated with the onset and course of juvenile depressive disorder include high parental criticism, family discord and poor

communication between parents and adolescent. There are widely differing denitions of the activity of family therapy, but most therapies have the following features in common. First, they typically involve face-to-face work with more than one family member. Second, therapeutic work focuses on altering the interactions among family members. Third, practitioners think of improvement at two levels that of the presenting problem and that of the relationship patterns associated with the problem.

Signs and Symptoms of Depression

Teenagers face a host of pressures, from the changes of puberty to questions about whom they are and where they fit in. The natural transition from child to adult can also bring parental conflict as teens start to assert their independence. With all this drama, it isnt always easy to differentiate between depression and normal teenage moodiness. Making things even more complicated, teens with depression do not necessarily appear sad, nor do they always withdraw from others. For some depressed teens, symptoms of irritability, aggression, and rage are more prominent. Signs And Symptoms of Depression In Adolescents:

Sadness or hopelessness Irritability, anger, or hostility Tearfulness or frequent crying Loss of interest in activities Changes in eating and sleeping Habits

Restlessness and agitation Feelings of worthlessness and guilt Lack of enthusiasm and motivation Fatigue or lack of energy Difficulty concentrating Thoughts of death or suicide

Effects of Teenage Depression

The negative effects of teenage depression go far beyond a melancholy mood. Many rebellious and unhealthy behaviors or attitudes in teenagers are actually indications of depression. The following are some the ways in which teens act out or act in in an attempt to cope with their emotional pain:

Problems at school. Depression can cause low energy and concentration difficulties. At school, this may lead to poor attendance, a drop in grades, or frustration with schoolwork in a formerly good student. Running away. Many depressed teens run away from home or talk about running away. Such attempts are usually a cry for help. Drug and Alcohol Abuse. Teens may use alcohol or drugs in an attempt to self-medicate their depression. Unfortunately, substance abuse only makes things worse. Low self-esteem. Depression can trigger and intensify feelings of ugliness, shame, failure, and unworthiness. Internet addiction. Teens may go online to escape from their problems. But excessive computer use only increases their isolation and makes them more depressed.

Reckless behavior. Depressed teens may engage in dangerous or high-risk behaviors, such as reckless driving, out-of-control drinking, and unsafe sex. Violence. Some depressed teens (usually boys who are the victims of bullying) become violent. As in the case of the Columbine school massacre, self-hatred and a wish to die can erupt into violence and homicidal rage.

Teen depression is also associated with a number of other mental health problems, including eating disorders and self-injury.

Suicidal Warning Signs In Adolescents

Teens who are seriously depressed often think, speak, or make "attention-getting" attempts at suicide. An alarming and increasing number of teenagers attempt and succeed at suicide, so suicidal thoughts or behaviors should always be taken very seriously. For the overwhelming majority of suicidal teens, depression or another psychological disorder plays a primary role. In depressed teens who also abuse alcohol or drugs, the risk of suicide is even greater. Because of the very real danger of suicide, teenagers who are depressed should be watched closely for any signs of suicidal thoughts or behavior. Suicidal Warning Signs In Adolescents

Talking or joking about committing suicide. Saying things like, Id be better off dead, I wish I could disappear forever Speaking positively about death or romanticizing dying (If I died, people might love me more). Writing stories and poems about death, dying, or suicide. Engaging in reckless behavior or having a lot of accidents resulting in injury. Giving away prized possessions. Saying goodbye to friends and family as if for good. Seeking out weapons, pills, or other ways to kill themselves.

Risk of Teenage Antidepressant Use

In severe cases of depression, medication may help ease symptoms. However, antidepressants arent always the best treatment option. They come with risks and side effects of their own, including a number of safety concerns specific to children and young adults. Its important to weigh the benefits against the risks before starting your teen on medication.

Antidepressants And Teenage Brain

Antidepressants were designed and tested on adults, so their impact on the youthful, developing brain is not yet completely understood. Some researchers are concerned that the use of drugs such as Prozac in children and teens might interfere with normal brain development. The human brain is developing rapidly in young adults, and exposure to antidepressants may impact that developmentparticularly the way the brain manages stress and regulates emotions. Antidepressants Suicide Warning For Adolescents Antidepressant medications may increase the risk of suicidal thinking and behavior in some teenagers. All antidepressants are required by the U.S. Food and Drug Administration (FDA) to carry a black box warning label about this risk in children, adolescents, and young adults up to the age of 24. The risk of suicide is highest during the first two months of antidepressant treatment. Certain young adults are at an even greater risk for suicide when taking antidepressants, including teens with bipolar disorder, a family history of bipolar disorder, or a history of previous suicide attempts. Teenagers on antidepressants should be closely monitored for any sign that the depression is getting worse. Warning signs include new or worsening symptoms of agitation, irritability, or anger. Unusual changes in behavior are also red flags. According to FDA guidelines, after starting an antidepressant or changing the dose, your teenager should see their doctor:

Once a week for four weeks Every 2 weeks for the next month At the end of their 12th week taking the drug More often if problems or questions arise

Supporting an Adolescent through Depression Treatment

As the depressed teenager in his/her life goes through treatment, the most important thing one can do is to let him or her know that someone is there to listen and offer support. Now more than ever, the teenager needs to know that he or she is valued, accepted, and cared for.

Be understanding. Living with a depressed teenager can be difficult and draining. At times, one may experience exhaustion, rejection, despair, aggravation, or any other number of negative emotions. During this trying time, its important to remember that your child is not being difficult on purpose. The teen is suffering, so do your best to be patient and understanding. Encourage physical activity. Encourage the teenager to stay active. Exercise can go a long way toward relieving the symptoms of depression, so find ways to incorporate it into teenagers day. Something as simple as walking the dog or going on a bike ride can be beneficial.

Encourage social activity. Isolation only makes depression worse, so encourage your teenager to see friends and praise efforts to socialize. Offer to take your teen out with friends or suggest social activities that might be of interest, such as sports, after-school clubs, or an art class. Stay involved in treatment. Make sure the teenager is following all treatment instructions and going to therapy. Its especially important that the child takes any prescribed medication as instructed. Track changes in the teens condition, and call the doctor if depression symptoms seem to be getting worse. Learn about depression. Read up on depression so that one can be your their expert. The more one knows, the better equipped theyll be to help depressed teen. Encourage the teenager to learn more about depression as well. Reading up on their condition can help depressed teens realize that theyre not alone and give them a better understanding of what theyre going through. The road to depressed teenagers recovery may be bumpy, so be patient. Rejoice in small victories and prepare for the occasional setback. Most importantly, dont judge oneself or compare ones family to others. As long as theyre doing their best to get teen the necessary help, theyre doing their job.

Objectives

The main aim of choosing the topic was to get a better understanding about Depression in Adolescents. It was also done to know more about how adolescents can cope up with depression as well as how it can be prevented among them. Also, certain topics like aetiology, symptoms, prevention of depression etc., are also covered.

Literature Review

Jaycox LH 2009; Impact of teen depression on academic, social, and physical functioning. This study aimed to determine the impact of teen depression on peer, family, school, and physical functioning and the burden on parents. Patients participated in a longitudinal study of teens with and without probable depression, drawn from 11 primary care offices in Los Angeles, California, and Washington, DC. A total of 4856 teens completed full screening assessments; 4713 were eligible for the study, and 187 (4.0%) met the criteria for probable depression and were invited to participate, as were teens who were not depressed. A total of 184 baseline assessments for teens with probable depression and 184 for non-depressed teens were completed, as were 339 (90%) parent interviews. Follow-up interviews were conducted with 328 teens (89%) and 302 parents (82%). Measures included teen reports of peer and parent support, 2 measures of school functioning, grades, physical health, and days of impairment. Parent reports included peer, school, and family functioning and subjective and objective burdens on parents. Teens with depression and their parents reported more impairment in all areas, compared with teens without depression at baseline, and reported more coexisting emotional and behavioral problems. Both depression and coexisting problems were related to impairment. There was a lasting impact of depressive symptoms on most measures of peer, family, and school functioning 6 months later, but controlling for coexisting baseline emotional and behavioral problems attenuated this relationship for some measures. Improvements in teen depression might have benefits that extend beyond clinical symptoms, improving peer, family, and school functioning over time.

Jensen PS-1996; Outcomes of mental health care for children and adolescents: II. Literature review and application of a comprehensive model. Using a comprehensive model of outcomes, the authors review the scientific literature to determine the extent of knowledge concerning the outcomes of mental health care for children and adolescents.Previous research is examined to determine the degree to which it addresses five salient outcome domains: symptoms/diagnoses, functioning, consumer perspectives, environments, and systems (the SFCES model). Despite numerous studies, only 38 met minimal scientific criteria. They generally fall into two categories, according either to their focus on the efficacy of treatment(s) for specific disorders or the effectiveness of a particular service or service system. Only two studies include outcome assessments across all five domains. As health care practices shift, improvements in mental health care will require credible evidence detailing the impact of clinical treatments and services on all salient outcome domains. Embedding efficacious treatments into effective service programs will likely improve care, but treatments will require modification to make them flexible, inclusive, and appropriate to multicultural populations. Furthermore, service delivery systems must be modified to meet the specific clinical needs of children with mental disorders and to embrace new efficacious treatments as they become available.

Keller MB-1991; Depression in children and adolescents: new data on 'undertreatment' and a literature review on the efficacy of available treatments. This article reports on the treatment received by 38 adolescents during an episode of major depression which had a median duration of 4 months. The one subject who received any pharmacologic treatment was prescribed an antianxiety agent. Sixteen percent received psychotherapy. These results are consistent with evidence from studies of adults indicating that depression is under recognized and undertreated. An important caveat is that the small sample size limits the generalizability of these findings. Moreover, which medication should be prescribed when a diagnosis of depression is made is not yet known with certainty, as literature reviews indicate that more controlled trials of psychotherapeutic and psychopharmacologic treatments for adolescents with depression are needed to better understand the efficacy of treating depressed adolescent.

Parker G-2001; Adolescent depression: A Review The aim of the study was to review the characteristic clinical, illness course and risk factors to adolescent depression. A literature review is provided with interpretive comments. The clinical feature profile is likely to reflect the rarity of melancholic depression, while the non-melancholic "irritable hostile" pattern appears distinctly increased. A "reactive depressive disorder" is rare in those who get to psychiatric assessment, while comorbidity (e.g. anxiety and personality disorders, illicit drug use) is the rule. Aetiological determinants and the prognosis generally more relate to comorbid factors than to depression per se. Predisposing and precipitating psychological and social determinants are considered, while the efficacies of varying antidepressant strategies remain unclear apart from those with an "anxious" or "irritable" depression where selective serotonin re-uptake inhibitor medication has shown utility and where cognitivebehavioural therapy may be relevant. For the majority who develop adolescent depression, its expression and outcome appear more a reflection of the propagating determinants, most commonly anxiety and personality style. The clinician should determine a treatment plan that not only addresses the depression but which identifies and addresses the contributing features.

John Manafas-2011; Adolescent depression and the socioeconomic crisis: review

Children and teens are a particularly vulnerable segment of the population. The vulnerability of this group and unique nature of adolescent depression along side a socioeconomic crisis make it a major public health issue for Greece. This paper conducts a preliminary review of available literature on the impact the Greek socioeconomic crisis will have on social determinants as mediators of mental health outcome: adolescent depression. Literature search was carried out using strictly online resource available through the University of Athens Medical School access accounts from local and international databases. By attempting to draw a connection from socioeconomic crisis to social determinants and on to adolescent depression, a considerable international knowledge-base was found addressing the subject from various points of view. Although none drew a clear path, some indirect evidence exists in the literature. At the same time further clarification is needed to understand adolescent depression development path and trajectory. Only some primarily conclusions can be extracted from the international literature and can be extended to the Greek socioeconomic crisis and adolescent depression to predict outcome.

TADS Team-2004; The Treatment for Adolescents With Depression Study (TADS): Demographic and Clinical Characteristics The TADS study was conducted at 13 sites in the United States, involving 428 patients aged 12 to 17 years with a primary diagnosis of major depression. Participants were randomly assigned to one of four treatments for 12 weeks: 1) fluoxetine (starting dose 10 mg adjusted to 40 mg/day) with clinical management (six 20 to 30 minute physician visits to monitor status and medication effects); 2) pill placebo with clinical management; 3) cognitive-behavioral therapy (CBT) in 15 sessions over 12 weeks; or 4) the combination of fluoxetine with CBT. Suicidal thoughts declined in all groups. A suiciderelated event occurred in 6% of the adolescents, without any significant difference among the four treatment groups. A broader measure of harm-related events (any self-harm or harm to another person or property) occurred more often (odds ratio 2.19) for patients receiving fluoxetine compared with those who were not. The combination of CBT and fluoxetine had the best outcome, with a response rate of 71% compared to 61% for fluoxetine alone, 43% for CBT alone, and 35% for placebo. The increased risk of harmrelated events in patients receiving fluoxetine requires careful monitoring in clinical practice. The combination of fluoxetine with CBT provided the most favorable tradeoff between benefits and risks for these adolescents with major depressive disorder.

Terri Jean Farmer-2006

Major depression affects up to 40% of U.S. adolescents in mild to severe forms, compromising emotional, academic, and relational functioning, including that of interacting with parents. The purpose of this study was to explore the parent-adolescent relationship during an episode of depression in order to elucidate the adolescent experience of being parented and the parental experience as it contributes to the context of the adolescent. Research questions included: 1) What are the depressed adolescents meanings and experiences of being parented? 2) How do the meanings and experiences of parenting contribute to the context of the life world of the depressed adolescent? An adapted Colaizzian (1978) method was used to phenomenologically analyze interview data from 6 adolescents and 5 parents. Findings for adolescents supported an essential pattern of Dysphoric Tension between Moving Away and Moving Toward, including themes of Feeling Devalued within the Relationship and Renegotiating the Relationship. Parent findings supported the essential pattern of Tension between Pulling Closer and Letting Go, with 4 themes including Losing the Familiar, At the Nexus of Action, Composing Life with the Stranger, and Crisis Management Within. The adolescent and parent findings were compared for differences and commonalities to assist in understanding the context provided by the parents. Findings were used to refine the investigators previous model of adolescent depression. Shaylyn Cunningham-2008; Anxiety, Depression and Hopelessness in Adolescents: A Structural Equation Model

This study tested a structural model, examining the relationship between a latent variable termed demoralization and measured variables (anxiety, depression and hopelessness) in a community sample of Canadian youth. The combined sample consisted of data collected from four independent studies from 2001 to 2005. Nine hundred and seventy one participants in each of the previous four studies were high school students (grades 10-12) from three geographic locations: Calgary, Saskatchewan and Lethbridge. Participants completed a battery of self-report questionnaires including the Beck Anxiety Inventory (BAI), Beck Depression Inventory-Revised (BDI-II), Beck Hopelessness Scale (BHS), and demographic survey. Structural equation modeling was used for statistical analysis. The analysis revealed that the final model, including depression, anxiety and hopelessness and one latent variable demoralization, fit the data and standardized error. Overall, the findings suggest that close relationships exist among depression, anxiety, hopelessness and demoralization. In addition, the model was stable across demographic variables: sex, grade, and location. Further, the model explains the relationship between sub-clinical anxiety, depression and hopelessness. These findings contribute to a theoretical framework, which has implications with educational and clinical interventions. The present findings helped to guide further preventative research in examining demoralization as a precursor to sub-clinical anxiety and depression.

Birmaher B-1996; Childhood and adolescent depression: a review of the past 10 years.

The aim of the research was to qualitatively review the literature of the past decade covering the epidemiology, clinical characteristics, natural course, biology, and other correlates of early-onset major depressive disorder (MDD) and dysthymic disorder (DD). A computerized search for articles published during the past 10 years was made and selected studies are presented. Early-onset MDD and DD are frequent, recurrent, and familial disorders that tend to continue into adulthood, and they are frequently accompanied by other psychiatric disorders. These disorders are usually associated with poor psychosocial and academic outcome and increased risk for substance abuse, bipolar disorder, and suicide. In addition, DD increases the risk for MDD. There is a secular increase in the prevalence of MDD, and it appears that MDD is occurring at an earlier age in successive cohorts. Several genetic, familial, demographic, psychosocial, cognitive, and biological correlates of onset and course of early-onset depression have been identified. Few studies, however, have examined the combined effects of these correlates. Considerable advances have been made in our knowledge of early-onset depression. Nevertheless, further research is needed in understanding the pathogenesis of childhood mood disorders. Toward this end, studies aimed at elucidating mechanisms and interrelationships among the different domains of risk factors are needed. Williamson DE-1995; A case-control family history study of depression in adolescents. The aim of the study was to examine whether depression aggregates in the families of depressed adolescents and to determine whether clinical features and/or comorbid syndromes in the depressed adolescents change the risk of psychopathology in relatives. Lifetime prevalence rates of psychopathology in the first-degree and second-degree relatives of 76 adolescents with major depressive disorder (MDD) and the first-degree and second-degree relatives of 34 normal control adolescents were assessed by the Family History-Research Diagnostic Criteria (FH-RDC) method using the parent/guardian as the family informant. Compared with the first-degree relatives of normal controls, the relatives of depressed adolescents had significantly higher lifetime rates of MDD (25% versus 13%) and "any" of the FH-RDC psychiatric disorders (53% versus 36%). The second-degree relatives of adolescents with MDD had significantly higher lifetime rates of FH-RDC "other" psychiatric disorder and "any" of the FH-RDC psychiatric disorders but not MDD compared with the relatives of normal controls. The first-degree relatives of depressed adolescents who were also suicidal had increased lifetime rates of suicidal behavior which significantly cosegregated with MDD. Comorbid conduct disorder in the depressed adolescent was associated with increased rates of antisocial personality disorder in the first-degree relatives and also tended to cosegregate with MDD. The current study provides further evidence for the familial aggregation of depression in adolescent-onset MDD. This study also suggests that the

familial aggregation of nonaffective psychiatric disorders depends on the clinical features and comorbid syndromes present in the depressed adolescent proband. Keller MD-1988; Course of major depression in non-referred adolescents: a retrospective study. This article reports on a naturalistic study of the course of illness of 38 children diagnosed as having a current or past episode of major depression out of a sample of 275 children who were selected by a method not related to their psychopathology or treatment-seeking behavior. Assessments of the presence of depression and the course of this disorder were made using structured clinical interviews (DICA and DICA-P) and a criterion-based diagnostic system (DSM-III). Longitudinal methods of data analysis included the use of life tables. The proportion of children depressed for 2 years closely resembles the results found in investigations of children who sought treatment for a psychiatric disorder. The probability of remaining depressed in these children was 21% at 1 year after onset, and 10% at the 2-year point. This parallels the rate of chronicity and the decline in rates of recovery which occur over time in adult depression. Rice J-1984; Sex-related differences in depression, Familial evidence. After a description of threshold models of familial transmission based on an underlying continuous liability distribution, family data from the NIMH-CRB Collaborative Psychobiology of Depression Program-Clinical are described. No sex differences are found for bipolar illness, whereas female relatives have an increased rate of primary unipolar illness when compared to male relatives. This effect persists when relatives are classified according to recurrence, current illness, onset within the last 10 years, and treatment. Moreover, a cohort effect is present in the data and indicates a sex ratio close to one in the young cohort (less than or equal to 25). We considered the transmission of illness from parent to offspring by using survival analysis to examine the proportion of ill brothers and sisters of probands according to the affection status of parents. A maternal effect is found, with the mother having a greater influence on the liability of offspring of either sex. This is at odds with the notion that males and females have identical liabilities, but females have a lower threshold reflecting acknowledgement of more symptoms, etc. However, the mean difference in liability between the sexes may be due to systematic biological/cultural differences, with parental transmission contributing to variation about their means.

Tanielian T-2009; Improving treatment seeking among adolescents with depression: understanding readiness for treatment.
The main aim of the study was to examine readiness for treatment among adolescents with depression in primary care. This article draws upon data from 184 depressed patients, aged

13 to 17, who participated in the Teen Depression Awareness Project. Adolescents were screened assessed along a number of domains at baseline and 6 months. Seventy-eight percent of the depressed teens acknowledged they had a problem with depression, yet only 25% were currently getting any sort of counseling or treatment for depression. A total of 40.8% of depressed adolescents were "ready" to get care, whereas 26.6% were "unsure" and 32.1% were "not ready." Significant differences among these groups were observed for race/ethnicity and household income. Adolescents in the ready group also had more depressive symptoms and lower MHI-5 scores. Being in the ready group versus being "unsure" was a significant predictor of service use at the 6-month follow-up, as was the average number of days impaired and overall mental health functioning. Race, gender, and age were not significant predictors of readiness, yet average number of depressive symptoms was significantly associated with greater readiness. Because teens in primary care settings are not seeking mental health treatments even when depression is detected, providers should be mindful that adolescents may be at different stages of recognition and readiness for treatment. Teens who are less ready for care may need follow-up primary care visits or consultation to help them become more active in seeking care.

Key Learning
The topic was an in-depth study of Depression In Adolescents. It helped to gain better knowledge about the disorder in teenagers. This study allowed having vast information related to this topic. From history to classification of depression, aetiology to treatment therapies, symptoms to prevention, all gave giant information on depression among adolescents. Being aware of the symptoms of teenage depression can help the people in his/her surrounding be sensitive to the disorder. This will help in its prevention as well. Knowing that depression in adolescents can also reach up to suicidal activities is a growing concern. This study helped in understanding its prevention as well as steps to prevent suicides due to depression in teenagers. Also, certain researches proved that depression among teenagers is present and is growing from the past decades. Depression has been defined by Hippocrates and Kraeplin as well. DSM-IV and ICD-10 has given their own understandings about depression.

Conclusion
Depression refers to a range of mental conditions characterized by persistent low mood, absence of positive affect (loss of interest and enjoyment in ordinary things and experiences), and a range of associated emotional, cognitive, physical, and behavioral symptoms. Symptoms occur on a continuum of severity, and day to day functioning is often impaired. Depressive disorder is frequent in primary care and general hospital practice but is often undetected. Unrecognized depressive disorder may slow recovery and worsen prognosis in physical illness, therefore it is important that all doctors be able to recognize the condition, treat the less severe cases, and identify those requiring specialist care. Depressive disorder can be clinically presented in the form of dysthymia, cyclothymia, postnatal depression disorder etc. depression in adolescents can be treated by using various therapies like family therapy, cognitive-behavioral therapy, interpersonal therapies etc. Special care by parents and peers should be taken when dealing with a depressed teen. They should be sensitive and should provide all the care and love that they need. Symptoms like withdrawl from social activities, losing interest in hobbies, hopelessness and helplessness, hostility and anger etc. should be given attention. The adolescent should be provided all the help s/he needs to prevent suicide. Depression also leads to suicidal thoughts and activities. Hence, depression among adolescents is a sensitive issue which is growing at a fast pace. Necessary steps should be taken in its prevention and to create a happier tomorrow for the adolescent.

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