Problem of the Young

It is not so universally recognized that sleep disorders also affect the young. Although there are few large-scale epidemiologic studies of daytime sleepiness in adolescents and young adults, existing data suggest that problem sleepiness affects a significant percentage of youths. About 25% of American children aged 1–5 experience some kind of sleep disturbance. From 20%–25% of 9th through 12th grade students reportedly experience behaviors associated with problem sleepiness, such as difficulty getting up for school, falling asleep in school, or struggling to stay awake while doing homework. According to one report, 54%–75% of adolescents and young adults expressed “a wish for more sleep” because they were experiencing morning tiredness. In a survey of high school students, it was found that many students got less than 6.5 hours of sleep on school nights; only 15% reported sleeping 8.5 hours or more.

Together, these data indicate a widespread pattern in childhood of inadequate sleep and consequent problem sleepiness. The chart lists some of the more common problems associated with poor sleep patterns.

Physician Visits

Sleep problems in children 16 years old or younger are severe enough to trigger many visits to physicians by anxious parents. The most widely prescribed drugs for sleep disorders are psychotherapeutics, sedatives, and antihistamines. Drugs regularly prescribed include diphenhydra-mine, chloral hydrate and Imipramine (sold as Antideprin, Deprimin, Deprinol, Depsonil, Dynaprin, Eupramin, Imipramil, Irmin, Janimine, Melipramin, Surplix, Tofranil).

Antidepressant medication has been surprisingly inefficacious for adolescents. In contrast to open studies, placebo-controlled, double-blinded research protocols have failed to demonstrate any benefit of medication over placebo for adolescent depression. Up to 60% of adolescents recover while receiving placebo; up to 70% recover using medication. This finding applies to traditional tricyclic antidepressants, such as imipramine, desipramine, and nortriptyline, and also to serotonin reuptake inhibitors, such as fluoxetine. However, numbers in studies of the more recent medications have been limited.

When is medication indicated? Medication should be considered early in treatment for certain situations:

• psychotic episodes,

• vegetative symptoms,

• severe functional impairment,

• bipolar disorder,

• panic disorder,

• obsessive compulsive disorder, and

• strong family history of depression.

Psychosis and bipolar disorder usually require psychopharmacologic intervention in the form of antipsychotics, benzodiazepines, and mood-stabilizing agents, such as lithium and carbamazepine. The approach is similar to that for adults and is reviewed elsewhere. Medication should be considered seriously when there are comorbid conditions for which antidepressant medications have clearly been demonstrated effective, even for adolescents. These include obsessive compulsive disorder, panic disorder, bulimia, and attention deficit disorder.

Despite the lack of demonstrated efficacy of antidepressant therapy for adolescents, some leading researchers point out that, once placebo responded have been eliminated, a group of patients who appear to respond well to medication remains. Therefore, a trial of medication is justified when a serious major depressive episode fails to respond to nonpharmacologic interventions. Many of these patients have prominent neurovegetative symptoms including severe sleep disturbance, weight change, and marked functional impairment. This approach has produced excellent results in specialty mood disorder clinics, which tend to see more severe cases that have not responded to other treatments.

If the clinical situation indicates medication, which medication is appropriate? Table 3 oudines suggested medications. Factors to consider are the safety profile, side effects, effectiveness of the medication for depression and comorbid conditions, cost, and likelihood of compliance with treatment.

Tricyclic antidepressants.Most of the earlier controlled studies found limited evidence of efficacy for this class of antidepressant, especially imipramine, desipramine, and recently nortriptyline. Because tricyclics are lethal in overdose, they cannot be used if there is a risk of suicidal behaviour, despite their low cost and long history of use. Limiting the amount of medication or placing it in the care of a family member are possible solutions if tricyclics are otherwise strongly indicated. Side effects, such as anticholinergic effects, sedation, and postural hypotension, are common and limit compliance. However, for certain young people, especially those with comorbid obsessive compulsive disorder, attention deficit disorder, or panic disorder, tricyclics are the drugs of choice. Also, controlled studies have shown desipramine helpful for attention deficit disorder and bulimia, and clomipramine is clearly effective for obsessive compulsive disorder.

Serotonin reuptake inhibitors. Because overdoses are not lethal, side effects are minimal, and they have an activating effect on anergic adolescent depression, serotonin reuptake inhibitors are the practical drugs of choice. Comorbid obsessive compulsive disorder, bulimia, and some panic disorder cases will also respond. Preliminary observations on the efficacy of fluoxetine for attention deficit disorder and impulse control disorders suggest that it might be more widely used if supported by future research. Anorgasmia is one upsetting side effect for some patients.

Other pharmacologic agents. Special situations call for other drug classes. Monoamine oxidase inhibitors are effective for the atypical depression, panic disorder, and social phobia often present in adolescent depression. Dietary restrictions, postural hypotension, and sexual dysfunction might limit compliance, and the risk of serious hypertensive crisis is worrying. The introduction of moclobemide, a reversible monoamine oxidase inhibitor that has no dietary restrictions, that is helpful for anxious depression, and that might also be useful for atypical depression, could solve these problems. Overdoses of moclobemide have not proved fatal to date.

Finally, using lithium as augmentation, or for recurrent depression, can be considered for adolescents as for adults, although specific effectiveness for adolescents has not been demonstrated.

Conclusion

The social, psychological, and developmental costs of adolescent depression are well documented. In most cases comprehensive psychosocial intervention is more effective treatment than pharmacotherapy. Because of the risk of recurrence and the presence of identifiable, persistent risk factors, emphasis during both evaluation and treatment must be on assisting the young person to develop more effective coping skills and a more positive cognitive and behavioural style. Current studies are examining the effect of psychological and pharmacologic treatments on outcome.

First, introduce the concept, using a simple example of how negative beliefs are self-reinforcing. The assumption of "catastrophic" outcomes occurs in daily life on flimsy evidence. Teens can usually think of an example that has happened in the previous few days. Physicians should then explain that "your mind dwells on that worst case scenario, and your body reacts as if that awful thing has already happened, so you feel terrible, and chemical changes of depression start to happen." When you describe how this idea is well supported by animal and human models, most adolescents will find the concept quite interesting.

The implication is that they have control over some aspect of their lives, which often feel out of control. Review a typical recent example from a patient’s own experience, looking at the assumptions and errors of thinking that occurred. After this first discussion, ask teens to look for more examples before the next meeting. This "homework" extends the effect of physician contact outside office time.

Cognitive therapy does not preclude an understanding of the origins of psychological problems. One additional idea that can be readily introduced is to touch on the life experiences that "taught" the adolescent this way of thinking. Risk factors, such as abandonment, abuse, learning disabilities, medical illness, parental separation, and so on, can be integrated and linked to the current depressive way of thinking. In this sense, what appears to be a purely cognitive type of therapy in fact has an insight-oriented component. Presented in a psychoeducational way, it helps adolescents make sense out of what have been overwhelming emotional responses to overwhelming life experiences.

At the next meeting, one or two of the previous week’s examples should be examined in detail, looking at the event, the assumptions, the emotional response, and alternative explanations for the events. Adolescents are then given more "homework" of trying out a behavioural change, such as deliberately making eye contact and smiling, to see if this changes experience. Other activating behavioural steps, such as exercise or the use of structure, can also be added in as "experiments" to see if they do make a difference in the depressed mood. It is important to point out that just as negative ways of thinking and behaving have been "practised" for a long time, the new ways of thinking and behaving will need practice too.

Among the tools for cognitive therapy are logic, humour, and creativity. The result of this approach is a more assertive and less dependent adolescent. The general behavioural approach that accompanies cognitive therapy leads to more effective problem solving and taking control wherever possible. The only "side effect" of this is that others in the family or social network might resist this new assertiveness and confidence. This needs to be anticipated with a systems approach.

Cognitive-behavioural changes need to be practised, but they rapidly prove themselves effective to adolescents, who then become their own therapists. Various books written for adult patients can also help adolescents develop greater understanding and more strategies for changing depressogenic cognitive distortions. Physician-coaches can then positively reinforce these steps through infrequent booster sessions.

Table 1 outlines psychotherapeutic approaches to adolescent depression. The emphasis is on cognitive therapy and behavioural strategies that not only help to resolve the current episode but will also make enduring changes in social and cognitive behaviours in order to prevent recurrent depression in high-risk individuals.

Principles of cognitive therapy. Cognitive therapy has been proven as efficacious as, or better than, medication for mild and moderate depression among adults. While research on the efficacy of group cognitive therapy for adolescents and cognitive-behavioural therapy for anxiety and impulse control disorders exists, research protocols

for individual cognitive therapy for depressed adolescents have not been developed. However, cognitive distortions are well demonstrated in depressed adolescents. The appeal of cognitive therapy for adolescents is that they are still learning and their cognitive style is more flexible than adults. In my experience, teens acquire cognitive-behavioural skills more rapidly than adult patients with mood disorders. Furthermore, the skills help teens gain some control over their lives and counteract learned helplessness. Family physicians can readily undertake cognitive therapy; they have the advantage of an already established therapeutic alliance.

The principle behind cognitive-behavioural therapy techniques is that depression is exacerbated, and might even be caused, by "depressogenic" cognitions, ways of thinking that are self-defeating and promote depression. The learned helplessness model has demonstrated the behavioural consequences of this kind of conditioned attitude in animals. Animal models also demonstrate the associated biochemical changes in the brain that accompany this behaviour. Describing to adolescents the model of helpless rats is often a helpful starting point for them to see their behaviour as "logical" given their experience.

The individual who has succumbed to learned helplessness typically believes that "It’s no use trying; it never works out for me anyway; I never do anything right; everything always goes wrong" and so on. A negative interpretation of events reinforces these beliefs. For example, when classmates walk past in the school hallway without acknowledging the depressed adolescent, the adolescent assumes: "They don’t like me; no one likes me; I’ll never have any friends." Depressive behaviour reinforces this belief. Depressed adolescents do not smile, do not make eye contact, and look at the floor; inevitably others will be less likely to greet them in the hall. This then "proves" the belief that they will never have any friends or that it is no use trying. Cognitive therapy challenges this belief, reexamining the evidence and seeking alternative explanations for the classmates’ unfriendly actions. "Perhaps they had other things on their minds, were worried about a test, were shy, thought I didn’t want to talk because I was avoiding eye contact," and so on. This is followed by behavioural "experiments" to test out these other hypotheses.

The cognitive-behavioural approach for young people is reviewed in detail elsewhere, but the general approach can rapidly be mastered by family physicians and applied in a brief counseling approach outlined below.

(French Language)

Le traitement de la dépression chez les adolescents comporte de multiples modalités, incluant des interventions de nature pharmacologique, psychothérapeutique, éducative et familiale. Les médicaments ont un rôle limité: leur efficacité est minimale, ils n’influencent pas les facteurs étiologiques et l’inobservance est un problème fréquent chez les adolescents. Les médecins devraient plutôt insister sur les mécanismes d’adaptation et les modalités efficaces de solution de problème pour prévenir la récurrence de la dépression.

In contrast to the treatment of depression in adults, medication has a limited role for treating adolescent depression. There are several reasons for this. First is the lack of efficacy (as described below) and second is the limited effect of medications on etiological factors. Because many risk factors, such as anxiety, and developmental and learning problems persist, they must be addressed specifically because they perpetuate the depression.

Third, adolescents are likely to be noncompliant with medication. They struggle with the idea of taking mood-altering substances recommended by adults while they are developing an independent identity and are subject to peer pressure. Adolescents have commented that taking pills proves to them that they are “psycho.” Finally, those adolescents who have developed clinical depression really need coping mechanisms and effective problem-solving styles in order to help repair the damaging effects of the depression and to prevent its recurrence.

Comprehensive approach

The principles for treating adolescent depression are:
• ensure confidentiality,
• establish rapport,
• assess suicide risk,
• involve the family, and
• maintain school supports.

Adolescents can rarely be treated successfully without the active support of the family and school. The teen’s academic load might need to be adapted, specific learning difficulties remediated, and school counseling provided to prevent development of school avoidance behaviour. The family’s inevitable frustration and criticism of the depressed teen’s “laziness” needs to be changed, and other contributing environmental factors addressed.

The comprehensive approach to adolescent depression includes some common sense measures, such as sleep hygiene, regular meals, exercise, time management, and combating social withdrawal. The immobilized, overwhelmed teen needs help with setting priorities to combat helplessness and hopelessness. A support system of caring adults and peers who will not simply give advice but will promote strengths and problem-solving is crucial. Depressed individuals need to take control of their lives because this is the antidote to hopelessness. Social skills and assertiveness training, stress management, and cognitive-behavioural strategies are among the more specialized tools that will benefit depressed adolescents.

Secondary prevention is an important aspect of the comprehensive approach. Risk reduction and improved coping strategies help to deal with factors that are often persistent. Understanding the role of these etiologic factors is critical for treating each individual case. For example, a young person with a strong family history of depression, who is at high genetic risk and who has had previous major depressive episodes, needs to be alerted to early symptoms of recurrence and taught preventive strategies and coping mechanisms to use while an active biological approach to treatment and maintenance therapy is instituted. On the other hand, an adolescent with a weak family history of depression and a strong history of developmental problems or psychosocial stressors will require a primarily psychotherapeutic and behavioural approach to prevent recurrence.

Managing suicidal thoughts. Adolescents are at special risk for suicidal behaviour. Follow-up studies have shown that depressed adolescents are at very high risk. One study showed that the most common method of completing suicide was tricyclic antidepressant overdose. While younger children have suicidal thoughts in the context of depression, they more rarely act upon them, perhaps because they lack the ability to formulate and carry out a plan. However, age of first suicidal behaviour might be declining, likely due to children’s greater awareness of potential methods, especially overdosing on nonprescription medications. Suicidal thoughts arise from a sense of hopelessness and isolation. The first step in preventing suicidal behaviour in a depressed adolescent is to develop rapport and a therapeutic relationship in which isolation is reduced and hopelessness combated by the more optimistic view of a physician or other professional. Emergency telephone numbers, crisis lines, or the ready response of a family physician or counselor are especially important for this age group. Adolescents will rarely abuse a 24-hour phone line to a physician, and this could be lifesaving.

Role of family therapy. In some cases, a depressed adolescent is the symptom of a family problem, and treatment could be ineffective if the problem is not identified at its source. An example is a severely depressed 15-year-old who was resistant to psychotherapy and pharmacotherapy with full trials of two serotonergic reuptake inhibitors and a tricyclic antidepressant, failed to improve with psychiatric hospitalization, and remained functionally impaired and suicidal. During a second hospitalization, the family secret came to light. Mother had a long-standing affair with another man who was in the role of substitute father for the children but needed to be concealed from their biological father. Chronic but unacknowledged marital conflict was fueling the hopelessness and helplessness of this bright teen. She felt responsible but paralyzed and was very much caught between the parents. Her depression finally began to resolve, without any medication, as the family faced the situation directly. Adolescents most vulnerable to developing “symptomatic” depression are those who are introverted, anxious, and conscientious, often excessively enmeshed in their parents’ problems and taking precocious responsibility for the well-being of the adults in the family. Parental depression or other serious psychiatric disorders, substance abuse, and covert marital problems are examples of the kinds of family problems an adolescent might be masking. Indeed, the adolescent’s symptoms could be the one factor uniting parents whose marriage is about to dissolve. A family therapy approach might be resisted by parents and siblings who have conspired to keep family secrets hidden. If a family physician is pressured to accept this conspiracy of silence, the outcome for the depressed adolescent is then poor.

Resources for nonpharmacologic interventions. The time-consuming work of nonpharmacologic intervention can be shared. Family physicians can draw upon many skilled community resources, such as school counselors, mental health centre’s, family services and social agencies, alcohol and drug programs, psychiatrists, psychologists, social workers, and other trained family therapists. It is crucial, however, that these agencies communicate with primary physicians and that all of the therapeutic interventions are integrated rather than contradictory. A safety net is created by parents, schools, physicians, and other agencies operating together on behalf of a depressed adolescent. Conflicting approaches and disagreement among the family, school, and various other professionals will only increase an adolescent’s sense of isolation and discouragement.

Comorbidity is the simultaneous occurrence of more than one diagnosis. Comorbidity complicates research on the etiology and outcome of a single diagnosis, such as depression, because the comorbid diagnosis might in fact be the main determinant of outcome. Table 3 lists commonly comorbid conditions.

The coexistence of multiple diagnoses is the norm rather than the exception in childhood depression. In fact, only about 20% of depressed teens will be diagnosed with uncomplicated depression. More than 50% of depressed adolescents will simultaneously meet criteria for an anxiety disorder; more than 50% will meet criteria for oppositional defiant or conduct disorder; and a similar percentage will have attention deficit hyperactivity disorder. Several studies indicate that almost 60% of patients have diagnoses in all four categories. Similar results emerge from studies of populations with a primary diagnosis of attention deficit disorder where high rates of depression and anxiety disorders are found. Many studies of comorbidity do not even include substance abuse or eating disorders, particularly bulimia nervosa, as an area of inquiry. Panic disorder and obsessive compulsive disorder are commonly seen with a complicating depression in our specialty mood disorders clinic.

Current research is ascertaining the effect of comorbid diagnoses on response to various treatments and on outcome. It happens, however, that many treatments overlap so that a comorbid diagnosis can guide treatment choices. Comorbid conditions, such as anxiety disorders and behavioural disorders, might respond well to specific pharmacotherapy or might respond to the nonpharmacologic measures used to treat depression. Behavioural, cognitive, and coping strategies are helpful for panic disorder, bulimia nervosa, obsessive compulsive disorder, and attentional or impulse control disorders, and as part of the management of conduct or substance abuse disorders.

Prognosis and outcome

Longitudinal studies of child and adolescent depression have recently been published. A long-term follow up of children seen at the Maudsley Hospital found that milder depressive symptoms appear to predict various nonaffective psychiatric problems and personality dysfunction in adulthood, while more severe acute depressive episodes are more likely to be followed by adult affective illness. In the shorter term, the morbidity over 3 to 5 years for adolescents with a major depression is alarming: impaired psychological, academic, and social functioning; recurrent depression; and a disturbing rate of serious suicide attempts. These data indicate that we should take adolescent depression seriously. ■

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.

An awareness of risk factors can help a physician detect the potential for clinical depression in a particular young person. Risk factors for depression in young people are many (Table 1). They can be integrated into a model of biological risk and psychological style interacting with developmental and environmental stressors to produce a final common pathway. Three times as many women as men develop clinical depression.

The genetic risks for early onset depression indicate that physicians should be more vigilant in assessing young people with depressed parents or siblings. Additional risk is noted when the depressed parent is the mother, suggesting an additive effect of biological risk and learned cognitive or behavioural patterns. Nevertheless, studies of adopted children and twins emphasize the independent role of genetic factors.

Those young people who have struggled with developmental problems, learning disabilities, and attention deficit disorder are more vulnerable to depression, presumably because of fragile self-esteem and learned helplessness.

Children with a chronic medical illness are vulnerable, and depressive symptoms can be challenging to elicit in the face of physical or pharmacologic causes of fatigue, sleep disturbance, and somatic complaints. Recognition and treatment of concurrent depression will improve quality of life and functioning for medically ill children.

Young people with constitutionally high anxiety and anxiety disorders are prone to depression. A neurochemical basis for chronic anxiety, involving the depletion of neurotransmitters, might lead to secondary depression. Independent of this, the psychological effect of chronic anxiety promotes depression. Somatic anxiety and cognitive worry interfere with concentration and coping, eroding self-confidence. The experience of anxiety promotes the catastrophic cognitive distortions known as the "depressogenic" cognitive style. Anxiety can interfere with acquiring social skills and hence hinder success in various domains important to self-esteem. Anxiety disorders increase the risk for relapse and chronic depressive disorders.

Psychosocial stressors increase the risk of developing depression. A common event is parents’ separation, which is a risk factor particularly for adolescent girls, even if the separation occurred many years earlier. Young people develop a sense of helplessness and guilt regarding their inability to prevent marital separation. They do not trust the stability of key relationships and they fear abandonment. A relationship loss might trigger a depressive episode.

Finally, the effect of childhood neglect, abandonment, and abuse is clearly a risk factor.13 This applies particularly to early onset prepubertal depression, which is likely to persist chronically into adolescence as dysthymia, with potential for recurrent superimposed major depressive episodes.

Examination of the risk factors for adolescent depression reveals that a common mechanism is learned helplessness promoted through the tendency to develop overwhelming anxiety and through the experience of being abused, neglected, unsuccessful, repeatedly defeated, or helpless in the face of traumatic stressors. A sense of vulnerability, worthless-ness, and guilt pervade, and coping mechanisms are limited.

(French Language)

Chez les adolescents, la dépression clinique amène une morbidité significative, incluant une détresse somatique et une altération du fonctionnement cognitif, interpersonnel et académique. Les facteurs de risque sont clairement identifiables et les médecins de famille devraient les rechercher attentivement. La dépression est le principal facteur de risque du suicide chez les adolescents.

Depression among young people has received increasing clinical and research attention in the past decade. Community studies have documented an alarming prevalence of clinical depressive syndromes among adolescents, with 4.7% of non-referred adolescents aged 14 to 16 years suffering major depressive disorder and 3.3% suffering dysthymic disorder (chronic minor depression) at any given time. The rate among adolescent girls is at least three times that among boys. The rate is higher and the age of onset is earlier among offspring of parents with major depression. Longitudinal studies confirm an increase in the rate of major depression. One study found that the cumulative probability of having a major depression by the age of 20 is 0.50 among siblings of children with a major depressive episode. More disturbing is the 0.20 cumulative probability by the end of the teen years among those adolescents not judged high risk by family history. The increase has been accompanied by an increase in the rate of adolescent suicide, for which depression is the greatest risk factor.

The high prevalence and alarming cumulative risk of developing clinical depression during adolescence establishes adolescent depression as an important primary care problem. Depressive episodes usually last 6 to 9 months and often recur. Depressed teens are likely to care for themselves poorly, fail in school, and disappoint themselves and others, becoming alienated from both peers and adults. They have persisting deficits in academic functioning, self-esteem, and social competence. The interruption of normal adolescent development by a depressive episode has a high cost, as deficits persist over several years. Because most cases will not be seen by mental health professionals, recognition and treatment by primary care physicians is essential.

Recognition

“Depression” might be a passing mood, a natural reaction to a life event, an excessive reaction of a vulnerable individual to a stressor, or a clinical syndrome of varying severity. The recognized and validated clinical syndromes are dysthymic disorder (chronic mild depression), major depressive disorder, and the depressive phase of bipolar (manic-depressive) disorder. On any given day, about 40% of 14-year-olds will describe themselves as “unhappy”; the actual prevalence of major depressive disorder is about 10% of this figure. Making this distinction is a diagnostic challenge.

Most depressed teens will not come to a family physician’s office complaining of depression but usually of fatigue and various somatic symptoms. Often, parents are concerned when school performance declines and hours are spent in bed. Teachers and parents sometimes see the crisis as behavioural rather than emotional, with the result that these teens do not come to medical attention because they are seen primarily as oppositional and “lazy.” The predominant mood can be irritable rather than depressed. Substance abuse might be suspected. School avoidance is very common; most school-avoiding adolescents are in fact depressed.

The following summary of risk factors, differential diagnosis, and comorbid disorders will assist family physicians in detecting and diagnosing major depressive disorder in adolescence.