At some point, most parents will observe it in their kids: Sadness that seems to take a long time to lift, often brought on by a disappointment that, to a child, seems more important than it actually is. But what if those feelings don't subside? What solutions are available to parents when a child's feelings overwhelm them to the point that they're not interacting with others in a normal way?
When major depression – an insidious disorder that strikes kids during key formative years, when they're struggling to develop a positive self-image – occurs, the impact can be more debilitating than parents realize. And more than 2.5 percent of kids and 8 percent of teens do face major depression.
Today, mental health professionals better recognize depression in youth – and are much better prepared to provide effective and long-lasting treatment. However, parents are faced with several questions, including whether antidepressant medication should part of their child's treatment plan.
Almost a decade after the U.S. Food and Drug Administration approved the use of serotonin-enhancing drug Prozac for children 8 years and older, the use of all classes of antidepressant drugs to treat kids remains controversial. For parents, there is both a wealth of information – and misinformation – regarding the drugs and their side effects.
Benefits and the black box
Currently, two medications are FDA-approved for the treatment of depression in youth: The aforementioned Prozac and Lexapro, which is approved to treat children ages 12 years and older. However, a qualified medical professional can prescribe any medication on the market for off-label uses. Doses for children and teens are typically low – in the 10- to 20-milligram range.
Jon Markey, a Berkley-based child psychiatrist, says antidepressants are an effective tool used to fight depression, but they should never be used without proper oversight.
"Antidepressants can be very helpful to children," he says, "but the key is to monitor the patient. A child will need to come in to see their psychiatrist frequently and, the best case scenario, (the plan) always includes ongoing therapy."
Yet in 2003, the FDA issued a caution – followed by "black box" warnings added to antidepressant labels in 2004 – that use of the meds could increase the risk of suicidal thoughts among kids and adolescents. That cast a cloud over using the medications to treat children, says David Rosenberg, M.D., director of child and adolescent research services at the Wayne State University Department of Psychiatry and Behavioral Neurosciences in Detroit.
"There was a drop in the use of antidepressants, (and) there was an increase in suicides," he says. "It was biggest increase that we saw in several years, so clearly, the medication was helping young people."
The FDA study that led to the label showed that of 2,200 children treated with serotonin-enhancing medications, 4 percent experienced suicidal thinking or behavior. Two percent of kids taking a placebo exhibited the same behavior. No child in the study committed suicide.
Risks: By the numbers
Antidepressants do pose some risks, like suicidal ideas and worsening symptoms of depression and irritability, to name a few – though the medical community still debates whether the FDA study established a definitive link between the use of antidepressants and increased suicidal thoughts.
However, a 2007 National Institutes of Mental Health study called Treatment for Adolescents with Depression noted most children respond positively to the medication.
In a clinical trial of 439 kids ages 12-17, NIMH found 71 percent responded to a combo treatment of Prozac and cognitive behavioral therapy after 12 weeks. For meds-only, it was 61 percent – and down to 43 percent for therapy only. By contrast, only 35 percent responded to a placebo treatment.
Medical professionals also point to youth suicide rates, which were trending down after serotonin-enhancing drugs came on the market. The Centers for Disease Control and Prevention's Annual Summary of Vital Statistics found the suicide rate spiked 18 percent in young people 19 years old and under between 2003 and 2004 – after the FDA issued the warning that led to a drop in antidepressant use among children.
Watch and listen
Selective serotonin re-uptake inhibitors, or SSRIs – which include Prozac and Lexapro – affect chemical messengers known as neurotransmitters, which triggers a complex process that can alter mood. But because children's brains are still developing, their response must be strictly monitored by medical professionals – and parents.
Georgia Michalopoulou, Ph.D., chief of staff for child psychiatry and psychology at Children's Hospital of Michigan in Detroit, says this monitoring is vital for all depressed children, especially if a kid is taking medication.
"Parents should watch their child very closely," she says. "Medical professionals need feedback to determine whether the drug is working to treat a child, and they absolutely need to be informed about any changes in the patient's behavior."
No child should ever be prescribed an antidepressant without a thorough medical and psychological work-up – the best way to make an accurate diagnosis. This will determine if a child responds to therapy alone, if their depression is chronic, if there's a family history of depression and if there are substance abuse issues.
That's key because medications for depression may not be effective against other conditions like bipolar disorder, obsessive-compulsive disorder or anxiety disorders, Michalopoulou says. And because all children are unique, there's no cookie cutter fix in terms of medication or therapy.
"Ongoing therapy – talking with children – is an effective strategy when treating depression," she says, "along with medication."
Typically, parents need to take their child to his or her psychiatrist or mental health professional every week for up to one to two months, followed by bimonthly appointments. Once it's determined that a medication is working – and that side effects are minimal or not life-threatening – appointments may get less frequent, Michalopoulou says.
If a child engages in any warning signs once on medication – like suicidal thoughts, self-harm, panic attacks, hostility or other behavior – the child should be taken in for an appointment with a mental health professional as soon as possible.
And a parent should never discontinue an antidepressant medication without first speaking with the child's physician or mental health counselor – because abruptly stopping medications can cause withdrawal effects or a relapse.
Going it alone
Even if a parent ultimately decides to go without antidepressants, it's important that depressive symptoms not go unchecked, says Rosenberg.
"We know that depression can be a lethal condition for anyone, and this is especially true for children," he says. "Getting a child into a treatment program is a necessary step in helping a child cope."
Because children who are depressed are also going through the same challenges as unaffected children, it can be difficult for a depressed child to develop a healthy level of self-esteem at home and at school.
Michalopoulou says solutions exist for children and their families.
"A combination of medication and therapy – as well as monitoring – should produce a good result," she says. "But no matter what type of treatment takes place, it's important for parents to act."
Signs and symptoms
Moody behavior and sullenness are often considered hallmarks of tween and teen years. But when these feelings are prolonged and more intense than usual, it may be time to take your son or daughter to see a mental health professional.
Here are some important signals to watch for if you suspect your child is experiencing a shift from normal sadness into major depression.
Emotional and behavioral
- Intense anger over trivial matters: Overreacts to an event or perceives comments and actions to be slights or criticisms.
- Poor grades: Shows a sudden shift in his or her interest in subjects that were once enjoyed – or a sudden drop in academic performance.
- Lack of interest in hobbies, friends: Stops engaging in activities and stops socializing with friends.
- Anxiety: Is nervous, upset, anxious or panicked over small issues, or for no reason.
- Feelings of hopelessness, negativity: Obsesses over real or perceived faults, pessimism or the inability to see himself or others in a positive light.
- Lack of focus: Loses concentration at school and at home.
- Inability to connect emotionally: Suddenly can't seem to talk about his or her problems openly.
- Suicidal thoughts: Expresses thoughts of death.
- Changes in appetite: Is eating significantly more, or less, than usual.
- Sleep disturbances: Can't get to sleep or wakes up frequently during the night. Sleeping too much, or not being able to wake up, is also a sign of depression.
- Sluggishness: Participates in fewer physical activities, moving slowly, delayed or minimal reaction to stimuli.
- Self-injury: Any activity that causes physical harm to a child's body, such as cutting, or taking risks that could result in injury.
Butt out, or in?
Children – especially tweens and teens – fiercely guard their privacy. And for the most part, parents try to respect their children's need for autonomy.
But when a parent suspects their son or daughter is suffering from depression – a condition which can be lethal – moms and dads need to set the potential for accusations of spying aside and intervene, says Rosenberg with WSU.
"When it comes to depression, I wouldn't worry about that," he says. "Depression is a condition that can't be ignored, and once a child is in treatment, he or she will understand your decision."
Depressed children and teens are need of an immediate intervention, and the consequences of not acting can be tragic. According to a 2007 study by the National Institute of Mental Health, 90 percent of people who commit suicide suffer from depression or other mental illnesses. Suicide was also the third-leading cause of death among young people ages 14 to 25, according to the study.
Luckily, hacking into your child's Facebook page isn't required to get information you need to make decisions about your kid's emotional health, says Michalopoulou of Children's Hospital of Michigan.
"The most important thing for parents is to ask questions," she says. "Ask the child how they're feeling or how things are going at school. They may not want to talk about it at first, but they need to know that a parent is concerned about them and their well-being."
Though it's common for kids to push back, it's a parent's role to set boundaries and rules for children. And parents need to do whatever they can to get between a child and depression, says Rosenberg.
"The worst thing a parent can do is nothing," he says. "It's not the time to worry about being intrusive."