Depression Symptoms Treatment

Differential diagnosis

If unhappiness is common, how do we know an adolescent is clinically depressed rather than having "normal" teenage moods? Differential diagnosis of depressive symptoms is based on history and mental status examination (Table 2). Obtaining histories from teens can be challenging, and a good sense of rapport and confidentiality will be important before important issues, such as substance abuse, can be evaluated.

The diagnostic criteria for depressive disorders among adolescents are the same as for adults. Adolescents are more likely than younger children to have hypersomnia, lethargy, weight gain, and psychomotor retardation. Essentially, major depression can be diagnosed in a young person with a depressed or irritable mood and at least 2 weeks of four or more of the following symptoms: insomnia or hypersomnia, appetite disturbance, weight change, impaired concentration, low energy, feelings of worthlessness or guilt, and suicidal ideas or gestures. Clear immediate precipitants, such as bereavement or other losses, must be ruled out.

Because such symptoms so frequently appear in the short term, some authors suggest emphasizing clear impairment in function in several spheres and persistence for 4 or more weeks. For practical purposes, this approach is used in the University Hospital’s Mood Disorders Clinic to reduce the potential for overdiagnosis in the teen population. On the other hand, one model of depressive disorder development suggests that brief, mild, depressive periods in response to stressors sometimes precede more significant autonomous episodes or even contribute to their development through a kindling mechanism similar to that in seizure disorders.

Parents and teachers report adolescents’ depressive symptoms poorly, but are good informants for behaviours. Hence the most accurate diagnosis will be achieved with both teen and parent informants. Adolescents might have difficulty keeping a clear perspective over time. Many teens, while in a depressive episode, will insist that they have "always been depressed," suggesting an underlying dysthymia contrary to parental reports that suggest a relatively recent onset. The same teen, when recovered, will give quite a different history, and the episodic nature of the depression will become clear.

An important diagnosis to consider is the depressed phase of bipolar disorder. Risk factors are family history of bipolar disorder, psychotic depression, and recurrent brief depressive episodes with psychomotor retardation. The manic phase is often missed because it can be brief, attributed to "teenage rebellion," and mistaken for or complicated by drug use. Careful history and family informants will usually reveal the facts.

Substance abuse complicates diagnosis, because it can produce a picture suggesting clinical depression, but can also mask depression when an adolescent struggles to change the dysphoric mood through mood-altering recreational drugs or alcohol.

Teens who have prolonged somatic and cognitive symptoms after suffering infectious mononucleosis, influenza, or other viral syndromes in which post-viral depression is commonly seen present a diagnostic challenge. A complicating major depressive episode in these cases might have indeed been triggered by the infection for both psychological and physiological reasons. Failure to diagnose the depressive disorder can lead to inadequate or ineffective treatment.