Answers to questions families often have about caring for their child with depression

Depression is not a choice or a character flaw. It is a treatable mental illness. Left untreated, it can lead to severe impairment in the ability to function. Extensive research supports biological, psychological, and social/environmental contributions to the development of a depressive disorder. Biological contributions to depression include genetics (family history), and many treatments address suspected chemical alterations in individuals with depression. Some people may be at higher risk of developing depression during significant life stress. A single “cause” of depression may not be obvious in some individuals.

People with depression may present in different ways. The types, severity, and duration of symptoms may differ from person to person and across episodes for the same person. Episodes of untreated depression can last from months to years, though most episodes last six to twelve months.

Signs and symptoms may include:

• Sad, anxious, or "empty" feelings that do not go away
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Irritability, restlessness, impatience (in children and adolescents, irritability may be more common than sadness)
• Loss of interest in favorite things or activities
• Fatigue and a lack of energy
• Problems concentrating, remembering details, and making decisions
• Sleeplessness (insomnia), sleeping too much, or trouble staying asleep
• Overeating or appetite loss
• Thoughts of suicide, suicide attempts
• Aches or pains, headaches, cramps, or digestive problems that do not go away even with treatment.

Because the diagnosis of depression is largely clinical, the first step is to visit a primary care doctor or mental health professional. Certain medications and some physical health problems, such as thyroid issues, can cause symptoms that mimic depression. A clinician can evaluate these possibilities by doing a physical exam, interview, and lab testing.

Once other causes of depressive symptoms are evaluated and ruled out, a mental health evaluation can help to identify the type of depression and the best treatment approach. Mental health evaluations can be done in the primary care setting, but more complex issues may require referral to a mental health professional. In addition to detailed questions about the patient’s current symptoms of depression, the clinician should ask about any family history of depression or other mental health conditions, alcohol or drug use, and thoughts of death or suicide. Once diagnosed, a person with depression can be treated in several ways depending on their needs.

Most depression can be managed in the outpatient setting with psychotherapy and/or medication, along with support from family and friends. Depressive episodes are likely to return – up to 70% of teens with major depression will have some recurrence within 5 years. If left untreated, a major depressive episode may diminish within 6-12 months from symptom onset. Treatment with psychotherapy and/or medications helps to shorten the duration of symptoms and leads to improvement for many individuals. The risk of self-harm or suicide can be decreased in most cases with treatment.

Depression appears to have a genetic component, although no specific genes that cause depression have been identified. The risk of depression in people who have a parent or sibling with depression is about 2 times as high as someone in the general population.

Depression, even in severe cases, can be effectively treated. The earlier that treatment starts, the more effective it tends to be.

In some cases of mild to moderate depression, psychotherapy alone may be a reasonable treatment option. Ensuring good sleep practices, adequate nutrition, and exercise can also help with some symptoms of depression. However, depression can also affect a person’s ability to sleep or motivation to take care of themselves. So, relying solely on lifestyle changes without addressing depression through other treatment options may not be helpful for everyone.

More severe depression may benefit from a combination of medications and psychotherapy. Individuals with depression and their families should make this decision with their primary care clinician to work together to evaluate the risks and benefits. Be aware that the benefits of treatment may take a while to notice, sometimes up to 4-6 weeks after starting treatment.

Most depressive episodes last from 6 months to 1 year, so the general recommendation for medications is to continue taking them for at least 1 year from symptom improvement. Therapy should also continue for at least that long.

Depression in youth can present with physical symptoms (frequent headaches or stomachaches), irritability, school refusal, clinginess to caregivers, or worry about the safety of others. Some children with depression may not actually feel sad but notice that they feel angry. Older children may appear sad, get into trouble at school, change friend groups, appear more irritable, experiment with drugs and alcohol, and feel misunderstood. Because some of these signs may be viewed as normal mood swings typical of children growing up, it may be hard to diagnose a young person with depression accurately.

Before puberty, boys and girls are equally likely to develop depression. By age 15, however, girls are twice as likely as boys to have had a major depressive episode. Depression in the teenage years often co-occurs with other conditions, such as anxiety, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), eating disorders, or substance use disorder. It can also lead to an increased risk of suicide.

Talking to your child about mental health can be uncomfortable due to the stigma involved and lack of information. It is important to have open conversations with your child about mental health to help reduce this stigma. Try asking your child how they are feeling and if anything is bothering them. Listen to them and validate their experiences. Be sure to let your child know they are not to blame for their feelings and that mental illness does not mean they are a “bad person.” For more ideas on how to start the conversation, refer to this resource from the National Alliance of Mental Illness (NAMI).

It can be difficult navigating the healthcare system when trying to get care for your child. Reach out to your child’s pediatrician or primary care provider with your concerns. Contacting school counselors and community mental health centers can also get your child the help they might need. For help finding a healthcare provider, refer to the directory.

If you notice any warning signs that your child or adolescent is at risk for attempting suicide, call or text the 988 Suicide & Crisis Lifeline at 988. You can also contact the Crisis Text Line (text HELLO to 741741). Both services provide 24/7 confidential support to anyone experiencing suicidal thoughts or emotional distress. If your child has attempted suicide, call 911.

Many pediatricians and primary care providers can diagnose and treat depression in youth. These providers often work closely with other mental health professionals, such as child and adolescent psychiatrists or therapists. Referral to a psychiatrist may be necessary if your child continues to struggle with depression despite appropriate treatment in primary care or if additional symptoms seem to indicate a different diagnosis.

In 2007, the FDA issued a Black Box Warning for antidepressant use in children and youth up to age 25 taking antidepressant medication. In about 4% of children and youth who took part in studies of antidepressants, some worsening of suicidal thinking occurred (compared to 2% of placebo). In over 4000 study subjects, no one died by suicide. However, suicidal thoughts are also a symptom of depression, and these studies were not designed to test for this effect. In the years after the Black Box Warning, prescribing rates of antidepressants went down, and suicide rates appeared to increase, suggesting the possibility of undertreated depression in some youth. For mild depression, antidepressant medications may pose more risk than benefit. It is important to discuss and weigh the risks and benefits of all treatment options with your mental health provider as it pertains to your situation. It is also important to notify your prescriber of any concerning side effects, including increased suicidal thoughts. Do not make medication changes without consulting your prescriber.

Other mental illnesses may present before depression or be a result of it. Depression and other mental and physical illnesses interact differently in different people. Identifying and treating co-occurring illnesses can help with treatment response and overall functioning.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), panic disorder, social phobia, and generalized anxiety disorder, often accompany depression. Alcohol and other substance use disorders may also co-exist with depression, and unidentified substance use may make treatment for depression less effective. Treating depression can also help improve the outcome of treating the co-occurring illness.