Depression and Depressive Disorders

Introduction

Depression is quite widespread and one of the leading causes of disability in the world. Commonly recognized symptoms of all types of depressive disorders are recurring feelings of sadness and guilt, changes in sleeping patterns such as insomnia or oversleeping, changes in appetite, decreased mental and physical energy, unusual irritability, the inability to enjoy once-favored activities, difficulty in working, and thoughts of death or suicide. (Dobson, 2004) If only these “down” symptoms are experienced, the individual may suffer from a unipolar depressive disorder such as dysthymia or major depression. If the depressed periods alternate with extreme “up” periods, the individual may have a bipolar disorder.

Dysthymia is a relatively mild depressive disorder that is characterized by the presence of two or more of the symptoms listed above. The symptoms are not severe enough to disable the affected individual, but are long-term (chronic), and may last for several years. Dysthymia is a compound word originating in Greek that means ill, or bad, (dys-) soul, mind, or spirit (thymia). Individuals affected with dysthymia often also experience episodes of major depression at some point in their lives. (Lang, 2004: McKendree, 2003)

In major depression, the affected individual has five or more symptoms and experiences one or more prolonged episodes of depression that last longer than two weeks. These episodes disrupt the ability of the affected individual to the point that the person is unable to function. Individuals experiencing an episode of major depression often entertain suicidal thoughts, the presence of which contribute to this disorder being quite serious.

Major depression should not be confused with a grief reaction such as that associated with the death of a loved one. Some individuals affected by major depression may experience only a single bout of disabling depression in their lifetimes. (McKendree, 2003) More commonly, affected individuals experience recurrent disabling episodes throughout their lives.

Bipolar disorder, formerly called manic depression or manic-depressive illness, is not nearly as common as major depression and dysthymia. Bipolar disorder is associated with alternating periods of extreme excitement (mania) and periods of extreme sadness (depression). The rate of the transition between cycles is usually gradual, but the mood swings may also be severe and dramatically rapid. When in the depressive state, the bipolar disorder affected individual may show any or all of the common symptoms of depression.

In the manic state, the bipolar disorder affected individual may feel restless and unnaturally elated, have an overabundance of confidence and energy, and be very talkative. Mania can distort social behavior and judgment, causing the affected individual to take excessive risks and perhaps make imprudent decisions that can have humiliating or damaging consequences. Without medical treatment, bipolar disorder may progress into psychosis.

Depressive disorders are believed to be related to imbalances in brain chemistry, particularly in relation to the chemicals that carry signals between brain cells (neurotransmitters) as well as the hormones released by parts of the brain. Serotonin and neuroepinephrine are two important neurotransmitters. Disruption of the brain’s circuits in areas involved with emotions, appetite, sexual drive, and sleep is a likely cause of the dysfunctions associated with depressive disorders. Thus, some of the newest treatments for depression are drugs that are known to have an effect on brain chemistry.

Genetic profile

Depression is known to be genetically linked because it often runs in families and has been studied in identical twins, but the specific gene markers for depression remain elusive. As of early 2000, the National Institutes of Mental Health has begun enrolling patients in what will become the largest clinical psychiatric genetic study ever attempted to investigate how recurrent depression is transmitted across generations. This study is primarily focused on major depression and dysthymia. (Lang, 2004)

In familial cases of bipolar disorder, the most widely implicated genetic regions are those of chromosome 18 and chromosome 21. However, other researchers have mapped bipolar disorder to chromosomes 11p, Xq28, 6p, and many others. From this evidence, it is possible that bipolar disorder is a multi-gene (polygenic) trait requiring a combination of 3 or more genes on separate chromosomes for the condition to be expressed. (Dobson, 2004) Further research is also ongoing to determine the genetic marker, or markers, for bipolar disorder.

It is understood that there are also many non-genetic factors that cause depression, including stressful environmental conditions, certain illnesses, and precipitating conditions such as the loss of a close relationship. Alcohol abuse and the use of sedatives, barbiturates, narcotics, or other drugs can cause depression due to their effect on brain chemistry.

Demographics

It is estimated that the likelihood of experiencing an episode of major depression during one’s lifetime is 5%. Approximately 9.5% of the American population, or 19 million people, are affected by depression in any given year. Depression occurs worldwide, but more Americans are diagnosed with depression than inhabitants of any other country. These lower occurrences of diagnosis in other parts of the world might indicate a higher incidence of depression in Americans than in all other peoples, but it may also be the result of the stigma, or shame, often associated with the diagnosis of a psychological disorder. Depression is not generally linked to any particular race of people. (Allen, 2006)

In the United States, women experience depression at a rate that is almost twice that of men. This may be partially explained by the greater willingness of women to seek psychological treatment, but this does not explain the entire discrepancy. Many physical events specific to women, such as menstruation, pregnancy, miscarriage, the post-partum period, and menopause are recognized as factors contributing to depression in women.

Women in the United States may face environmental stresses with a higher frequency than men. Most single parent households are headed by women; women still provide the majority of child and elder care, even in two-income families; and women are generally paid less than men so financial concerns may be greater.

Particular demographic problems associated with depression are depression in the elderly and depression in children and adolescents. A common belief is that depression is normal in elderly people. This is not the case, although increasing age and the absence of interpersonal relationships are associated with higher rates of depression. Because of this misconception, depressive disorders in the elderly population often go undiagnosed and untreated. (McKendree, 2003) Similarly, many parents often ignore the symptoms of a depressive disorder in their children, assuming that these symptoms are merely a phase that the child will later outgrow.

Signs and symptoms

Individuals affected with depressive disorders display a wide range of symptoms. These symptoms vary in severity from person to person and vary over time in a single affected individual.

Symptoms that characterize a depressive state are: feelings of hopelessness, guilt, or worthlessness; a persistent sad or anxious mood; restlessness or irritability; a loss of interest in activities that were once considered pleasurable; difficulty concentrating, remembering, or making decisions; sleep disorders, including insomnia, early morning awakening, and/or oversleeping; constant fatigue; eating disorders, including weight loss or over-eating; suicidal thoughts and/or tendencies; and persistent physical symptoms that do not respond to the normal treatments of these symptoms, such as headaches, digestive problems, and chronic pain. (Lang, 2004)

Symptoms that characterize a manic state are: increased energy accompanied by a decreased need for sleep, a loss of inhibitions accompanied by inappropriate social behavior, excessive enthusiasm and verve, increased talking, poor judgment, a feeling of invincibility, grandiose thinking and ideas, unusual irritability, and increased sexual desire.

Diagnosis

Depression is notoriously difficult to diagnose because its symptoms are not readily apparent to the medical professional unless the patient first recognizes and admits to them. Once the individual seeks help for his or her symptoms, the first step in the diagnosis of a depressive disorder is a complete physical examination to rule out any medical conditions, viral infections, or currently used medications that may produce the effects also seen in depression.

Alcohol or other drug abuse as a possible cause of the observed symptoms should also be investigated. Once a physical basis for these symptoms is eliminated, a complete psychological exam should be undertaken. This examination consists of a mental status examination; a complete history of both current and previously experienced symptoms; and a family history. (Allen, 2006)

The mental status examination is used to determine if a more severe psychotic condition is evident. This mental status examination will also determine whether the depressive disorder has caused changes in speech or thought patterns or memory that may indicate the presence of a depressive disorder. The complete psychological exam also includes a complete history of the symptoms being experienced by the affected individual. (McKendree, 2003)

This history includes the onset of the symptoms, their duration, and whether or not the affected individual has had similar symptoms in the past. In the case of past symptoms, a treatment history should be completed to assess whether these symptoms previously responded to treatment, and if so, which treatments were effective. The final component of the complete psychological exam is the family history. In cases where the affected individual has had similarly affected family members a treatment history should also be completed, as much as possible, for these family members. (Lang, 2004: Kramer, 2005)

Until recently, it was thought that children and adolescents could not suffer from clinical depression. It was assumed that children were not physically or psychologically mature enough to develop symptoms of depression and that adolescents with mood difficulties were simply going through “growing pains.” (Joffe, 2002) However, several investigations have shown that if appropriately evaluated, children and adolescents do suffer from depression.

We will refer to clinical depression that presents with severe symptoms as major depressive disorder (MDD) and depression that has moderate, chronic symptoms as dysthymic disorder (see below for specific criteria). Depression is relatively common; the prevalence (number of cases in one year) of MDD and dysthymic disorder combined is approximately 2 percent for children and 6 percent for adolescents. (Dobson, 2004)

Clinical features

Every child and adolescent can be occasionally and appropriately sad. However depression is more than just having a sad mood for a while. Children and adolescents with depression have a pervasive change in mood as well as a number of other clinical characteristics. There are four types of depression that child psychiatrists diagnose in children and adolescents: major depressive disorder (MDD), dysthymic disorder, adjustment disorder with depressed mood, and bipolar depression. (Wasserman, 2006: Joffe, 2002) Bipolar disorder (previously called manic-depressive illness) is another type of mood disorder consisting of periods of mania and depression. The diagnostic criteria and clinical presentation of the depressed phase of bipolar disorders is similar to that of MDD.

Major depressive disorder (MDD)

MDD is the most severe form of depression and has the most prominent clinical symptoms. Symptoms of MDD include:

1. persistent depressed or irritable mood most of the day (easily annoyed, angry, sad, anxious, hopeless; sometimes described as not having any emotion)
2. markedly diminished interest or pleasure in all or almost all activities (not able to enjoy activities that were previously fun, easily bored, sits around and does not do much)
3. significant weight loss or gain
4. sleep disturbance (trouble falling asleep, staying asleep, waking up too early, or sleeping more than usual)
5. psychomotor retardation (appearing to have slowed-down thinking and movements) or agitation (new onset of restless activity, pacing, unable to stay still)
6. fatigue or loss of energy (frequent complaints of feeling tired or having to push hard to do usual activities)
7. feelings of worthlessness or excessive guilt (very self-critical, blaming self for minor transgressions)
8. difficulty concentrating (distractible, unable to focus on challenging tasks, forgetful, indecisiveness)
9. thoughts of death or suicide, or attempting suicide

According to the American Psychiatric Association, to be diagnosed with MDD, the child or adolescent must have at least five of the above symptoms nearly every day for at least two weeks, and one of those symptoms must be either:

1. depressed or irritable mood; or
2. loss of interest and pleasure.

These symptoms must represent a change from previous functioning and produce impairment in relationships with others or in performance of usual activities. The symptoms and change in mood cannot be attributed to abuse of drugs, use of medications, certain severe psychiatric illnesses, bereavement, or medical illness. (Esherick, 2004)

Overall, the clinical picture of childhood MDD parallels the symptoms of adult MDD, with some minor differences. In children, symptoms of anxiety (including phobias and trouble separating from caretakers), physical complaints, and behavioral problems seem to occur more frequently. Adolescents tend to have more sleep and appetite disturbances, psychosis (hallucinations or delusions), and impairment of functioning than younger children. In addition, the incidence and severity of suicide attempts increase after puberty. (Wasserman, 2006)

Dysthymic disorder

Dysthymic disorder consists of a persistent, long-term change in mood which is generally less intense than in MDD. The associated symptoms of dysthymic disorder are not as severe as MDD. To be given a diagnosis of dysthymic disorder, the child or adolescent must have depressed mood or irritability on most days for most of the day over a period of one year, as well as at least two of the following symptoms:

1. change in appetite;
2. sleep disturbance;
3. low self-esteem;
4. poor concentration or difficulty making decisions;
5. decreased energy; or
6. feelings of hopelessness. (Kramer, 2005)

In addition, they may have other symptoms, such as feelings of being unloved, anger, somatic complaints (such as stomach aches, nausea, or headaches), anxiety, and sometimes disobedience. (Joffe, 2002)

Adjustment disorder with depressed mood

Sometimes children and adolescents experience an excessive change in mood in response to a very stressful event or a series of stressful events. If they develop a persistently depressed mood (often with tearfulness and hopelessness) and impairment of functioning within three months of the stressor(s), but do not meet criteria for MDD or dysthymic disorder, then they would receive a diagnosis of an adjustment disorder with depressed mood. (Smith, 2003)

An adjustment disorder does not have the associated symptoms of MDD or dysthymic disorder. It is important to emphasize that MDD or dysthymic disorder may be precipitated by stressful events, so that if a child or adolescent has the appropriate symptoms, they should receive a diagnosis of MDD or dysthymic disorder. (Mark, 2007) The prevalence, clinical course, and treatment of adjustment disorder with depressed mood have not been well studied in children and adolescents; a few studies indicate that it lasts for approximately six months and usually does not recur.

Presentation to outside observers

The diagnosis of depression can be difficult because the depressed and irritable mood often makes the child and adolescent less able and willing to share how they are feeling. Some of the symptoms of depression are difficult for others to observe because they are related to how the person is feeling inside. Parents and teachers may only notice that the depressed child or adolescent has become withdrawn, whiny, or moody. Little things make them angry or tearful, and they tend to view many situations as negative or overwhelming. (Wasserman, 2006) They interact less with others and withdraw from favorite activities such as sports, social events, or extracurricular activities.

Their school performance often declines, and the child may start to get into trouble at school or skip classes. However when clinically assessed, the depressed child or adolescent will often report sad mood, low energy, poor concentration, sleep or appetite changes, feelings of worthlessness or hopelessness, and thoughts of suicide. This underscores the necessity of gathering information from both outside observers and the child herself when assessing for depression.

Coexisting psychiatric disorders

Forty to 70 percent of children and adolescents with clinical depression also have other coexisting psychiatric diagnoses, such as disruptive behavior disorders (conduct disorder, oppositional-defiant disorder, and attention deficit/hyperactivity disorder), anxiety disorders, abuse of drugs and/or alcohol, and eating disorders (bulimia and anorexia nervosa). (Esherick, 2004: Smith, 2003) Identification and treatment of the coexisting psychiatric disorders may be important for the overall treatment of the depression.

Clinical course

MDD episodes tend to last approximately 7-9 months, and about 90 percent of the major depressive episodes end by 1.5-2 years after the onset. Between 6 and 10 percent of MDD episodes become chronic. Depression is a recurrent disorder; a child or adolescent experiencing a first episode of MDD has a 40 percent probability of developing another depressive episode within the next two years and 70 percent chance within the next five years. (Wasserman, 2006)

Follow-up studies of depressed adolescents have found that 20-40 percent of adolescents with MDD are at risk to develop bipolar disorder within a five year period after the onset of the depression. Characteristics associated with the conversion from MDD to bipolar disorder include the presence of psychomotor retardation and psychosis during the depression, family history of bipolar disorder or strong family history for mood disorders, and the development of agitation, high energy, or euphoria when taking antidepressant medications.

Furthermore, over a period of five years, approximately 70 percent of the children and adolescents with dysthymic disorders will develop an episode of MDD. Once these children have developed MDD, the course of their mood disorders follows the natural course of MDD. Therefore it may be very important to identify and treat childhood dysthymic disorder early. (William, 2006: Mark, 2007)

The most severe complications of depression are suicidal thoughts and suicide attempts. The adolescent suicide rate has more than tripled since 1950, and currently represents the third leading cause of mortality in this age group. Beyond depression, predisposing factors for suicidality include the existence of anxiety, disruptive, bipolar and personality disorders, and substance abuse. In addition, family history of depression or bipolar disorder, family history of suicidal behavior, exposure to family violence, impulsivity, and availability of methods (e.g., firearms at home) have been associated with an increased risk for suicide.

Children and adolescents with clinical depressions are at high risk for suicide, homicide, abuse of alcohol/drugs, physical illnesses, poor academic and psychosocial functioning. Moreover, after remission, previously depressed children may continue to show significant problems. These psychosocial problems tend to improve with time unless the depression develops again. The existence of other psychiatric disorders, family problems, and environmental stresses influences the risk for recurrent depression and suicide attempts.

Causes of clinical depression

Several factors are associated with the onset, duration, and recurrence of early onset MDD. Studies assessing relatives of depressed children and children of depressed parents have concluded that clinical depression runs in families. Investigations of twins who have been raised in separate families and other adoption studies have provided evidence that genetic factors predispose a person to develop clinical depression. Environmental factors such as exposure to negative events (e.g., deaths, divorce, medical illnesses), lack of support, family conflict, and aversive experiences in early childhood (neglect, death, abuse) may also contribute to the development of depression. (William, 2006: Gracelyn, 2006: Mark, 2007)

Several biological abnormalities, including changes in the secretion of the growth hormone and cortisol, have been linked to children and adolescents with depression. However there are no laboratory tests that diagnose MDD or dysthymic disorder. The most useful tools in diagnosing depression are

1. a thorough evaluation of depressive symptoms through interviews and observation of the child, and
2. interviews with parents and other key figures, such as teachers. (Esherick, 2004)

Treatment

Several treatment strategies, including different forms of psychotherapy and medication, have been developed for the treatment of MDD and dysthymic disorder in adults. Unfortunately, there has been relatively little research conducted with children and adolescents.

Psychotherapy for the acute treatment of MDD

Several types of psychotherapies have been used to treat MDD and dysthymic disorder in children and adolescents, including: psychodynamic psychotherapy, cognitive-behavioral therapy (CBT), family therapy, interpersonal therapy (IPT), social skills training, and group therapy. (Raymond, 2003) Though the manner of performing the different types of psychotherapy may vary, the overall goal of these therapies is to reduce the symptoms of depression. In addition, they generally try to improve the child’s coping skills, problem-solving abilities, academic functioning, parent-child and peer relationships, and, at times, understanding of internal psychological processes.

Cognitive-behavior therapy has been the most frequently studied psychotherapy in childhood and adolescent depression; it appears to be effective in the treatment of acute depression, prevention of relapses, and prevention of the onset of new depressions. (Mark, 2007) However, studies of other forms of psych! otherapy (IPT, family therapy, social skills training, group therapy) have shown that these forms of therapy are potentially effective as well in treating childhood depression.

It may also be important to include parents in the treatment process because:

1. children are dependent on their parents;
2. depressed youth frequently come from families with high rates of depression or high degree of conflicts; and
3. parent psychopathology and family conflict may predict a poor outcome to treatment and increase risk for depressive recurrences.(Mary, 2002)

Medication interventions for the acute treatment of MDD

Most of the studies published so far have evaluated the effects of the tricyclic antidepressants, such as nortriptyline (brand name Pamelor), imipramine (Tofranil), desipramine (Norpramin), and the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) in treating clinical depression. The studies show that some children and adolescents benefit from these medications.

In October of 2005 the Food and Drug Administration (FDA) issued a warning that children and adolescents taking SSRIs that were not previously approved by the FDA for use in children had been found to lead to an increased incidence of suicidal thoughts and behavior by the children and teens taking the medications. (Gracelyn, 2006) Although in many cases the benefits of these effective medications may outweigh the risks, close monitoring of children and adolescents taking SSRIs is important, especially during the first weeks the child is taking the medication. (Esherick, 2004)

Medications for treating depression differ in some ways from medications that people take for other medical illnesses. Though some people with depression notice a reduction in symptoms in a few days, most of the time there is a delay of up to 4-6 weeks for the medications to have an effect. The symptoms of depression usually do not improve all at once, but instead show a gradual and, at times, uneven improvement.

Once the depression has improved, there is evidence, at least in adults, that people with depression should keep taking medication for a period of time to prevent recurrence. Lastly, all antidepressants carry a small risk of triggering a manic or hypomanic (milder form of mania) episode in vulnerable patients. (For more information on medications, please refer to Antidepressants ). (Raymond, 2003)

Treatment of depression is on a case-by-case basis that is largely dependent on the outcome of the psychological examination. Some mildly affected individuals respond fully to psychotherapy and do not require medication. Some individuals affected with moderate or severe depression benefit from antidepressant medication. Most affected individuals respond best to a combination of antidepressant medication and psychotherapy: the medication to provide relatively rapid relief from the symptoms of depression and the psychotherapy to learn effective ways to manage and cope with problems and issues that may cause the continuation of symptoms or the onset of new symptoms of depression. (Gracelyn, 2006)

Various types of antidepressant medications are available for the treatment of depressive disorders. Many individuals affected by depression will go through a variety of antidepressants, or antidepressant combinations, before the best medication and dosage for them is identified. Almost all antidepressant medications must be taken regularly for at least two months before the full therapeutic effects are realized.

A full course of medication is generally no shorter than six to nine months to prevent recurrence of the symptoms. (Mary, 2002) In individuals affected with bipolar disorder or chronic major depression, medication may have to be continued throughout the remainder of their lives. These time-related conditions often pose problems in the management of individuals affected with depressive disorder.

Many individuals who have a depressive disorder discontinue their medications before the fully prescribed course, for a variety of reasons. Some affected individuals feel side effects of the medications prior to feeling any benefits; others do not feel that the medication is helping because of the delay between the initiation of the treatment and the feelings of symptom relief; and, many feel better prior to the full course and so cease taking the medication.

The three most commonly prescribed antidepressant drug classes consist of the older tricyclics (TCAs) and the two relatively new drug classes: the selective serotonin reuptake inhibitors (SSRIs) and the monoamine oxidase inhibitors (MAOIs). “The most common TCAs are amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin, Pertofrane), doxepin (Sinequan, Adapin), imipramine (Tofranil, Janimine), nortriptyline (Pamelor, Aventyl), protriptyline (Vivactil), and trimipramine (Surmontil).

The most common SSRIs are: citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). The most common MAOIs are: phenelzine (Nardil) and tranylcypromine (Parnate)”. (Horwitz, 2007)

Many antidepressant medications cause side effects such as agitation, bladder problems, blurred vision, constipation, drowsiness, dry mouth, headache, insomnia, nausea, nervousness, or sexual problems. Most of these side effects wear off as the treatment course progresses. The tricyclics cause more severe side effects than the newer SSRIs or MAOIs. (Gracelyn, 2006)

St. John’s wort is an herbal remedy that has been widely used to treat depressive disorders. In Germany, this herbal remedy is used more than any other antidepressant. As of early 2001, no scientific studies have been completed on the long-term effects of St John’s wort in the treatment of depression. In 2000, the National Institutes of Health (NIH) completed patient enrollment in a three- year clinical study to study this herbal treatment of depression. The results of this study should be available in late 2003 or in 2004.

In the most severely affected individuals, or where antidepressant medications either have not worked or cannot be taken, electroconvulsive therapy (ECT) may be considered. In the ECT procedure, electrodes are put on specific locations on the head to deliver electrical stimulation to the brain. This electrical stimulation is designed to trigger a brief seizure within the brain. (Raymond, 2003)

These seizures generally last approximately 30 seconds and are not consciously felt by the patient. ECT has been much improved in recent years; it is no longer the electro-shock treatment of nightmares, and its deleterious effects on long-term memory have been reduced. ECT treatments are generally administered several times a week as necessary to control the symptoms being experienced. (David, 2003)

Several short-term (10 to 20 week) psychotherapies have also been demonstrated to be effective in the treatment of depressive disorders. These include interpersonal and cognitive/behavioral therapies. Interpersonal therapies focus on the interpersonal relationships of the affected individual that may both cause and heighten the depression. Cognitive/behavioral therapies focus on how the affected individual may be able to change his or her patterns of thinking or behaving that may lead to episodes of depression. (Horwitz, 2007)

Psychodynamic therapies, which generally are not short-term psychotherapies, seek to treat the individual with a depressive disorder through a resolution of internal conflicts. Psychodynamic therapies are generally not initiated during major depression episodes or until the symptoms of depression are significantly improved by medication or one of the short-term psychotherapies.

Prognosis

Over 80% of individuals affected with a depressive disorder have demonstrated improvement after receiving the appropriate combination of treatments. A significant tragedy associated with depression is the failure of many affected individuals to realize that they have a treatable medical condition. Some affected individuals who do not receive treatment may recover completely on their own, but most will suffer needlessly. A small number of individuals with depressive disorder do not respond to treatment.

Prevention

Relapse and recurrences

Very few investigations of depression have addressed the prevention of relapses (reappearance of depression within two months of symptom resolution) and recurrences (a new episode of depression). After successful treatment with psychotherapy or medication, most patients have a relapse or recurrence. (David, 2003) Therefore, to prevent relapses, it is recommended that psychotherapy and/or medication treatments continue.

In adults, medication (with same dose that was used to cure the depression) may be continued for at least 16-20 weeks after achieving full remission of depressive symptom. In addition, various forms of psychotherapy can be used during the continuation period to help patients cope with the psychological and social difficulties produced by the depression and to manage the stress and conflicts that may trigger a depressive relapse or diminish medication compliance. (Horwitz, 2007)

To prevent recurrences, the length of therapy depends on several factors, such as severity of the depression, number of depressive episodes, chronicity, presence of psychotic symptoms, other psychiatric disorders, family psychopathology, and presence of an adequate support system. In adults, three to five years of psychotherapy and/or medication can significantly reduce the occurrence of additional MDD episodes. Community studies of adolescents have shown that group cognitive-behavioral therapy combined with relaxation and group problem-solving therapy may prevent recurrences of depression for up to 9-24 months after treatment.(Daniel, 2004)

Education and primary prevention

Prevention of depression for children and adolescents at high risk to develop depression, such as the offspring of depressed parents and children with some depressive symptoms, may be of prime importance.

Recent studies of high school adolescents and school children with some symptoms of depression, but not clinical depression, showed that cognitive interventions were effective in reducing depressive symptomatology and lowered the risk for developing depression for up to two years after the intervention. The prevalence and morbidity of depression in children and adolescents underscore the need for improved public awareness about depression, early detection and prompt treatment of depressed youths, and more research on the prevention and treatment of these disorders.

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