Depression Health Article

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. 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. 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 Parents and teachers may only notice that the depressed child or adolescent has become withdrawn, whiny, or moody.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. 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% 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). 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 1-9 months, and about 90% of the major depressive episodes end by 1.5-2 years after the onset. Between 6 and 10% of MDD episodes become chronic. Depression is a recurrent disorder; a child or adolescent experiencing a first episode of MDD has a 40% probability of developing another depressive episode within the next two years and 70% chance within the next five years.

Follow-up studies of depressed adolescents have found that 20-40% 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% 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.

The most severe complications of depression are suicidal ideation and suicide attempts. The adolescent suicide rate has quadrupled since 1950 (from 2.5 to 11.2 per 100,000), and currently represents 12% of the total 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.