Winning the WAR on Major Depressive Disorder
The word depression is used in many different
ways. People feel sad or blue when bad things
happen. However, everyday blues or sadness is
not a depressive disorder. People with the blues may have a short-term depressed mood, but they can manage to cope and soon recover without treatment.
The type of depression that is the focus of this
chapter is major depressive disorder-a type of
mood disorder and the most severe and most
disabling form of depression. Major depressive
disorder lasts for at least two weeks, affects
people's ability to carry out their work and
daily activities, and keeps people from having
satisfying personal relationships.
According to the National Survey on Drug Use and Health,
in 2014, 11.4 percent of youth ages 12-17 (an
estimated 2.8 million) experienced at least
one major depressive episode in the past
year. Among these youth, fewer than half (41.2
percent) received treatment for depression."
Depression is a serious mental health issue
that can affect even very young children. Major
depressive disorder affects approximately two
percent of preschool children and 3 percent of
pre-pubertal school age children at any given time.
Depression is often recurrent: a person recovers
but may develop another episode later on. If a
young person has an episode of depression,
they are more likely to have another episode
during their lifetime." Young people may also
experience depression as a side effect of certain
medications or when discontinuing use of a
medication." Depression often can occur with
attention deficit disorder, attention deficit/
hyperactivity disorder (ADHD), other disruptive
behavior disorders, anxiety disorders, and
substance use disorders."
When people think of depression, they typically
imagine someone who appears sad and
withdrawn. This is certainly true of some people
with depression. However, there are other signs,
particularly among young people, that may mean
depression is a problem.
Not every person who is depressed has all the
major symptoms. People differ in the number
of symptoms they have and how severe the
symptoms are. Even if a young person does not
have enough symptoms to be diagnosed with a
depressive disorder, some symptoms can still
have a significant impact on their life.
If a young person is clinically depressed, they would
have five or more of these symptoms (including at
least one of the first two) nearly every day for at least
two weeks:
• An unusually sad mood
• Loss of enjoyment and interest in activities that
were previously enjoyable
• Lack of energy and tiredness
• Feeling worthless or guilty when they are not
really at fault
• Thinking about death or wishing to be dead
• Difficulty concentrating or making decisions
• Moving more slowly or sometimes becoming
agitated and unable to settle
• Having sleeping difficulties or sleeping too much
• Loss of interest in food or sometimes eating
too much
• Changes In eating habits, which may lead to
either weight loss or weight gain
At home, young people may
• Complain of tiredness, even if they are sleeping
more than usual.
• Have difficulty doing household chores, either
forgetting to do them or not doing them
thoroughly.
• Withdraw from family, spending a great amount
of time in their bedroom.
•• Snap at family members, behave irritably, or
pick fights with parents or siblings.
• Avoid discussing important future events, such
as decisions about further education or work
opportunities.
In school, young people may
• Show a decline in school grades because they
do not complete work, do not do as good a job
as they used to do, or miss school,
• Fail to engage in classroom discussions or
struggle to understand and communicate.
• Snap at or start fights with other students or
engage in vandalism.
• Struggle to work effectively in the morning, but
do better in late afternoon classes.
These symptoms can all have an Impact on school
achievement. Some may result in disciplinary
responses. Teachers may also notice that a student
chooses topics such as depression, suicide, or
self-injury to write about in health or social science
classes or as the subject for creative writing or art.
In a social setting, young people may
• Avoid spending time with friends altogether.
• Spend more time with friends who appear to be
depressed as well.
• Become ostracized from their usual social group,
either because they continually refuse invitations
or friends find the individual difficult to spend
time with.
• Use alcohol or other drugs to deal with emotional
symptoms.
Many of the major symptoms of depression In youth
and adults are also symptoms of depression in very
young children. Children younger than age 12 with
depression may show aggressive behaviors, be more
fearful of new people and challenges, or show delays
or regression in important developmental milestones."
A young person who is depressed may actually
have a mood disorder called bipolar disorder
(previously known as manic-depressive
disorder. People with bipolar disorder have
episodes of depression, episodes of mania,
and periods of normal mood in between. The
time between these different episodes can vary
greatly from person to person. The depression
experienced by a young person with bipolar
disorder includes some or all of the symptoms
of depression listed earlier. Mania appears
to be the opposite of depression. A person
experiencing mania will have an elevated
mood, be overconfident, and be full of energy.
The person might be very talkative, full of ideas,
have less need for sleep, and take risks they
normally would not.
Bipolar disorder may have its onset in adolescence
or young adulthood. However, a person cannot
be diagnosed with bipolar disorder until they
have experienced both an episode of mania and
an episode of depression. Therefore, it may take
many years before a young person is diagnosed
correctly and receives the most appropriate
treatment. Males and females are equally affected.
A person experiencing mania will have some or
all of the following symptoms:
» INCREASED ENERGY AND OVER ACTIVITY
» ELEVATED MOOD
The person will feel high, happy, full of energy,
on the top of the world, and/or invincible.
» NEED LESS SLEEP THAN USUAL
The person can go for days with very
little sleep.
» IRRITABILITY
The person may become irritable if others
disagree with a manic person's unrealistic
plans or ideas.
» RAPID THINKING AND SPEECH
The person may talk too much, too fast, and
keep changing topics.
» LACK OF INHIBITIONS
The person may disregard risk, spend money
extravagantly, or be carelessly sexually active.
»GRANDIOSE DELUSIONS
These delusions involve very inflated
self-esteem, such as a belief that the
person is superhuman, especially talented,
or an important religious figure.
» LACK OF INSIGHT
The person is so convinced that manic
delusions are real that they do not realize
they are ill.
Young people with bipolar disorder may have
symptoms that are different from those seen in
adults, including more mixed episodes (feeling
manic and depressed at the same time), rapid
mood fluctuations, irritability, aggression, and
high emotional reactivity. Fewer adolescents
than adults with bipolar disorder experience the
euphoria typically associated with mania. In
adolescents, episodes may be less distinct than
in adults, may last longer, and they may have
a high level of symptoms between episodes.
Adolescents with bipolar disorder report they
are less likely to experience sleep disturbances
than adults with bipolar disorder. Bipolar
disorder has a high level of co-occurrence with
ADHD, substance use disorders, and anxiety
Disorders.
Depression has no single cause and often involves the
interaction of many diverse biological, psychological,
and social factors.
The following factors increase a
person's risk of developing depression:
• A history of depression in close family members
• Being a more sensitive, emotional, and anxious
person
• Adverse experiences in childhood, such as lack
of care or abuse
• Family poverty and social disadvantage
• Learning and other school difficulties
• Recent adverse events in the person's life, such
as being a victim of crime, death, or serious
illness in the family; having an accident; or being
bullied or victimized
• Parental separation or divorce
• Lack of a close, confiding relationship with
someone
• Long-term or serious physical illness
• Having another mental illness, such as an
anxiety disorder, psychotic disorder, or
substance use disorder
• Premenstrual changes in hormone levels
• Caring full-time for a person with a long-term
Disability."
Bullying is a common experience for many youth,
and it may be a contributing factor to developing
depression. One in 5 students ages 12-18 report being
bullied during the school year. Youth often do not tell
others that they are being bullied. Bullying behavior
can be physical or verbal and can occur in-person,
online, through email, and on social networking sites.
Youth who are
bullied experience real suffering that can interfere
with their social and emotional development as well
as their school performance. Some victims of bullying,
many with untreated depression, have even attempted
suicide rather than continue to endure such harassment
and punishment. The person doing the bullying
probably also needs help from an adult. Bullying is an
aggressive behavior that is intentional and involves an
imbalance of power and strength. A youth who bullies
may need counseling, along with supervision, clear
expectations, and consistent consequences.
Depression can also result from the use of medications
and other substances.
• The direct effects of some medical conditions, for
example, vitamin B12 deficiency, hypothyroidism,
hepatitis, glandular fever, HIV, and some cancers'
• The side effects of certain medications or drugs
(including some used to control acne)
• Intoxication from alcohol or other drugs
The symptoms of depression are thought to be
due to changes in natural brain chemicals called
neurotransmitters. These chemicals send messages
from one nerve cell to another in the brain. When
a person becomes depressed, the brain can have
less of certain of these chemical messengers. One
of these chemicals is serotonin, a chemical in the
brain that helps to regulate a person's mood. Many
antidepressant medications work by changing the
activity of serotonin in the brain.
Although depression is more common in women
than men, this pattern is not seen across the
whole lifespan. Some studies of depression in
childhood show that boys tend to have slightly
higher rates than girls. In adolescence, depression
increase, and girls begin to have two to three
times the rate of depression seen in boys.
There are several reasons why the gender
difference in depression emerges in adolescence.
One of these is hormonal. The rise in depression
in adolescent girls is associated with the onset
of puberty, with girls who reach puberty earlier
having more depressive symptoms. However,
other factors are involved as well.
For example, adolescent girls often invest more in
relationships with friends than boys do and are more likely
to become depressed when there are problems
in relationships. Girls are also more likely to
assume caretaking roles (e.g., with parents
or siblings), which can increase their risk for
depression.
The causes of bipolar disorder are not fully
understood. Having a close relative with bipolar
disorder, such as a parent or sibling, increases
an individual's risk for developing the disorder.
Of course, it is important to remember that more
than 90 percent of people who have a relative
with bipolar disorder will not develop the illness.
No other risk factors for bipolar disorder are
firmly established; however, some research
has demonstrated that the following issues
may lead to biochemical changes in the brain
that can lead to mania and depression:
» PREGNANCY AND OBSTETRIC COMPLICATIONS
Such complications may affect the developing
brain of the fetus or infant.
» BIRTH IN WINTER OR SPRING
This issue may reflect risk to the fetus from
infections or other events that vary by season.
» RECENT STRESSFUL LIFE EVENTS
Stressful events are more common in the
six months before onset of an episode.
» RECENT CHILDBIRTH
Women appear to be at increased risk in
the months after childbirth.
» BRAIN INJURIES
Brain injury before age 10 may increase risk.
» MULTIPLE SCLEROSIS
People with multiple sclerosis may have
increased risk.
»SOCIAL SITUATION
People who develop bipolar disorder are more
likely to have lower income, to be unemployed
and single, and to live in urban areas. However,
these factors may be consequences of the
very early changes produced by bipolar
disorder rather than the causes.
Early intervention is particularly important for
youth, because depression can have negative
effects on a young person's development?
Depression in youth is associated with delays in
social, emotional, and cognitive development.
Youth who have had depression are more likely to
have a range of problems in adulthood.
ways. People feel sad or blue when bad things
happen. However, everyday blues or sadness is
not a depressive disorder. People with the blues may have a short-term depressed mood, but they can manage to cope and soon recover without treatment.
The type of depression that is the focus of this
chapter is major depressive disorder-a type of
mood disorder and the most severe and most
disabling form of depression. Major depressive
disorder lasts for at least two weeks, affects
people's ability to carry out their work and
daily activities, and keeps people from having
satisfying personal relationships.
According to the National Survey on Drug Use and Health,
in 2014, 11.4 percent of youth ages 12-17 (an
estimated 2.8 million) experienced at least
one major depressive episode in the past
year. Among these youth, fewer than half (41.2
percent) received treatment for depression."
Depression is a serious mental health issue
that can affect even very young children. Major
depressive disorder affects approximately two
percent of preschool children and 3 percent of
pre-pubertal school age children at any given time.
Depression is often recurrent: a person recovers
but may develop another episode later on. If a
young person has an episode of depression,
they are more likely to have another episode
during their lifetime." Young people may also
experience depression as a side effect of certain
medications or when discontinuing use of a
medication." Depression often can occur with
attention deficit disorder, attention deficit/
hyperactivity disorder (ADHD), other disruptive
behavior disorders, anxiety disorders, and
substance use disorders."
When people think of depression, they typically
imagine someone who appears sad and
withdrawn. This is certainly true of some people
with depression. However, there are other signs,
particularly among young people, that may mean
depression is a problem.
Not every person who is depressed has all the
major symptoms. People differ in the number
of symptoms they have and how severe the
symptoms are. Even if a young person does not
have enough symptoms to be diagnosed with a
depressive disorder, some symptoms can still
have a significant impact on their life.
If a young person is clinically depressed, they would
have five or more of these symptoms (including at
least one of the first two) nearly every day for at least
two weeks:
• An unusually sad mood
• Loss of enjoyment and interest in activities that
were previously enjoyable
• Lack of energy and tiredness
• Feeling worthless or guilty when they are not
really at fault
• Thinking about death or wishing to be dead
• Difficulty concentrating or making decisions
• Moving more slowly or sometimes becoming
agitated and unable to settle
• Having sleeping difficulties or sleeping too much
• Loss of interest in food or sometimes eating
too much
• Changes In eating habits, which may lead to
either weight loss or weight gain
At home, young people may
• Complain of tiredness, even if they are sleeping
more than usual.
• Have difficulty doing household chores, either
forgetting to do them or not doing them
thoroughly.
• Withdraw from family, spending a great amount
of time in their bedroom.
•• Snap at family members, behave irritably, or
pick fights with parents or siblings.
• Avoid discussing important future events, such
as decisions about further education or work
opportunities.
In school, young people may
• Show a decline in school grades because they
do not complete work, do not do as good a job
as they used to do, or miss school,
• Fail to engage in classroom discussions or
struggle to understand and communicate.
• Snap at or start fights with other students or
engage in vandalism.
• Struggle to work effectively in the morning, but
do better in late afternoon classes.
These symptoms can all have an Impact on school
achievement. Some may result in disciplinary
responses. Teachers may also notice that a student
chooses topics such as depression, suicide, or
self-injury to write about in health or social science
classes or as the subject for creative writing or art.
In a social setting, young people may
• Avoid spending time with friends altogether.
• Spend more time with friends who appear to be
depressed as well.
• Become ostracized from their usual social group,
either because they continually refuse invitations
or friends find the individual difficult to spend
time with.
• Use alcohol or other drugs to deal with emotional
symptoms.
Many of the major symptoms of depression In youth
and adults are also symptoms of depression in very
young children. Children younger than age 12 with
depression may show aggressive behaviors, be more
fearful of new people and challenges, or show delays
or regression in important developmental milestones."
A young person who is depressed may actually
have a mood disorder called bipolar disorder
(previously known as manic-depressive
disorder. People with bipolar disorder have
episodes of depression, episodes of mania,
and periods of normal mood in between. The
time between these different episodes can vary
greatly from person to person. The depression
experienced by a young person with bipolar
disorder includes some or all of the symptoms
of depression listed earlier. Mania appears
to be the opposite of depression. A person
experiencing mania will have an elevated
mood, be overconfident, and be full of energy.
The person might be very talkative, full of ideas,
have less need for sleep, and take risks they
normally would not.
Bipolar disorder may have its onset in adolescence
or young adulthood. However, a person cannot
be diagnosed with bipolar disorder until they
have experienced both an episode of mania and
an episode of depression. Therefore, it may take
many years before a young person is diagnosed
correctly and receives the most appropriate
treatment. Males and females are equally affected.
A person experiencing mania will have some or
all of the following symptoms:
» INCREASED ENERGY AND OVER ACTIVITY
» ELEVATED MOOD
The person will feel high, happy, full of energy,
on the top of the world, and/or invincible.
» NEED LESS SLEEP THAN USUAL
The person can go for days with very
little sleep.
» IRRITABILITY
The person may become irritable if others
disagree with a manic person's unrealistic
plans or ideas.
» RAPID THINKING AND SPEECH
The person may talk too much, too fast, and
keep changing topics.
» LACK OF INHIBITIONS
The person may disregard risk, spend money
extravagantly, or be carelessly sexually active.
»GRANDIOSE DELUSIONS
These delusions involve very inflated
self-esteem, such as a belief that the
person is superhuman, especially talented,
or an important religious figure.
» LACK OF INSIGHT
The person is so convinced that manic
delusions are real that they do not realize
they are ill.
Young people with bipolar disorder may have
symptoms that are different from those seen in
adults, including more mixed episodes (feeling
manic and depressed at the same time), rapid
mood fluctuations, irritability, aggression, and
high emotional reactivity. Fewer adolescents
than adults with bipolar disorder experience the
euphoria typically associated with mania. In
adolescents, episodes may be less distinct than
in adults, may last longer, and they may have
a high level of symptoms between episodes.
Adolescents with bipolar disorder report they
are less likely to experience sleep disturbances
than adults with bipolar disorder. Bipolar
disorder has a high level of co-occurrence with
ADHD, substance use disorders, and anxiety
Disorders.
Depression has no single cause and often involves the
interaction of many diverse biological, psychological,
and social factors.
The following factors increase a
person's risk of developing depression:
• A history of depression in close family members
• Being a more sensitive, emotional, and anxious
person
• Adverse experiences in childhood, such as lack
of care or abuse
• Family poverty and social disadvantage
• Learning and other school difficulties
• Recent adverse events in the person's life, such
as being a victim of crime, death, or serious
illness in the family; having an accident; or being
bullied or victimized
• Parental separation or divorce
• Lack of a close, confiding relationship with
someone
• Long-term or serious physical illness
• Having another mental illness, such as an
anxiety disorder, psychotic disorder, or
substance use disorder
• Premenstrual changes in hormone levels
• Caring full-time for a person with a long-term
Disability."
Bullying is a common experience for many youth,
and it may be a contributing factor to developing
depression. One in 5 students ages 12-18 report being
bullied during the school year. Youth often do not tell
others that they are being bullied. Bullying behavior
can be physical or verbal and can occur in-person,
online, through email, and on social networking sites.
Youth who are
bullied experience real suffering that can interfere
with their social and emotional development as well
as their school performance. Some victims of bullying,
many with untreated depression, have even attempted
suicide rather than continue to endure such harassment
and punishment. The person doing the bullying
probably also needs help from an adult. Bullying is an
aggressive behavior that is intentional and involves an
imbalance of power and strength. A youth who bullies
may need counseling, along with supervision, clear
expectations, and consistent consequences.
Depression can also result from the use of medications
and other substances.
• The direct effects of some medical conditions, for
example, vitamin B12 deficiency, hypothyroidism,
hepatitis, glandular fever, HIV, and some cancers'
• The side effects of certain medications or drugs
(including some used to control acne)
• Intoxication from alcohol or other drugs
The symptoms of depression are thought to be
due to changes in natural brain chemicals called
neurotransmitters. These chemicals send messages
from one nerve cell to another in the brain. When
a person becomes depressed, the brain can have
less of certain of these chemical messengers. One
of these chemicals is serotonin, a chemical in the
brain that helps to regulate a person's mood. Many
antidepressant medications work by changing the
activity of serotonin in the brain.
Although depression is more common in women
than men, this pattern is not seen across the
whole lifespan. Some studies of depression in
childhood show that boys tend to have slightly
higher rates than girls. In adolescence, depression
increase, and girls begin to have two to three
times the rate of depression seen in boys.
There are several reasons why the gender
difference in depression emerges in adolescence.
One of these is hormonal. The rise in depression
in adolescent girls is associated with the onset
of puberty, with girls who reach puberty earlier
having more depressive symptoms. However,
other factors are involved as well.
For example, adolescent girls often invest more in
relationships with friends than boys do and are more likely
to become depressed when there are problems
in relationships. Girls are also more likely to
assume caretaking roles (e.g., with parents
or siblings), which can increase their risk for
depression.
The causes of bipolar disorder are not fully
understood. Having a close relative with bipolar
disorder, such as a parent or sibling, increases
an individual's risk for developing the disorder.
Of course, it is important to remember that more
than 90 percent of people who have a relative
with bipolar disorder will not develop the illness.
No other risk factors for bipolar disorder are
firmly established; however, some research
has demonstrated that the following issues
may lead to biochemical changes in the brain
that can lead to mania and depression:
» PREGNANCY AND OBSTETRIC COMPLICATIONS
Such complications may affect the developing
brain of the fetus or infant.
» BIRTH IN WINTER OR SPRING
This issue may reflect risk to the fetus from
infections or other events that vary by season.
» RECENT STRESSFUL LIFE EVENTS
Stressful events are more common in the
six months before onset of an episode.
» RECENT CHILDBIRTH
Women appear to be at increased risk in
the months after childbirth.
» BRAIN INJURIES
Brain injury before age 10 may increase risk.
» MULTIPLE SCLEROSIS
People with multiple sclerosis may have
increased risk.
»SOCIAL SITUATION
People who develop bipolar disorder are more
likely to have lower income, to be unemployed
and single, and to live in urban areas. However,
these factors may be consequences of the
very early changes produced by bipolar
disorder rather than the causes.
Early intervention is particularly important for
youth, because depression can have negative
effects on a young person's development?
Depression in youth is associated with delays in
social, emotional, and cognitive development.
Youth who have had depression are more likely to
have a range of problems in adulthood.