Depression is one of the most common mental health disorders.  At one time or another, everyone will experience feelings of depression. Feeling sad or depressed is a normal reaction to a tragedy, change, or a significant loss in our lives. For most people, the symptoms of depression are only temporary.

Depression is described in terms of the severity, duration and type of symptoms. The general feeling of depression is characterized by diminished motivation, low self-esteem, low energy, impaired thinking and emotional well-being.  Depression affects a person's overall energy, mood, expressions of emotion and behavior.

Depression is commonly referred to as a Mood Disorder.  Emotion is what you are feeling at a given moment. How you feel over a long period of time is your mood.

An estimated 1 out of 10 children have difficulty escaping the symptoms of depression for long periods of time. The rate of depression is markedly lower (1%) in children ages 1 to 6 years old. The rate is higher in older children ages 9 to 12 years (12%). Between 1 and 2 adults out of every 10 adults have significant symptoms of depression (10 to 20%).

There is reason to be concerned when symptoms of depression are severe, prolonged, unexpected, seem unusual or have no apparent cause. Recognizing the symptoms of depression can help you cope and seek help from a qualified mental health professional.

Symptoms Of Depression In Older Children And Adults

• Too much or too little sleep
• Significant increase or decrease in appetite
• Loss of interest or pleasure in others or most activities
• Feeling discouraged or worthless
• A significant drop in performance in school or at work
• Fatigue or loss of energy most of the time
• Restlessness, fidgeting or pacing
• Crying, feeling sad, helpless or hopeless
• Episodes of fear, tension or anxiety
• Frustration, irritability, emotional outbursts
• Excessive guilt or inappropriate self-blame
• Repeated medical complaints without a known medical cause (headaches, stomach aches, pain in arms or legs)

Additional Symptoms of Depression Found In Younger Children

• Emotionally brittle, temperamental, irritable or easily annoyed
• Loosing friends
• Repeated rejection by other children
• Inability to sit still, fidgeting or pacing
• Stays in room and isolates.
• Repeated emotional outbursts, shouting or complaining
• Avoids and doesn't talk to other children
• Irregular sleep habits (up at night and sleep during the day)
• Recent emergence of bed wetting

Serious And Critical Symptoms

• Suicidal thoughts, feelings or self-harming behavior 
• Aggressive, destructive, threatening or violent behavior
• Abuse or prolonged use of alcohol or other drugs
• Symptoms of depression combined with strange, bizarre or unusual behavior

Diagnosis

The correct diagnosis of depression is complicated. There are many alternative diagnostic systems and criteria for depressive syndromes. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is often used to diagnose depression.  There are growing concerns and criticisms of the DSM.  There are four DSM primary diagnostic categories involving depression.  They are,

• Major Depression. A severe form of depression that may involve disturbed sleep, appetite, suicidal thinking or self-harming behavior, loss of interest, problems thinking or concentrating, fatigue or loss of energy, restlessness or lethargy, and lowered self-esteem.

• Dysthymia. A less severe form of major depression in which symptoms are less evident and may appear chronic and last more than 2 years.

• Separation Anxiety Disorder. Depressive symptoms that are clearly associated with a very young child's separation from those to whom he or she is attached.

• Adjustment Disorder with depressed mood. Depressive symptoms that emerge as a reaction to an identifiable psychosocial stress. The reaction is viewed as maladaptive and the symptoms are considered in excess of what is usually expected.

There has been a tremendous amount of research regarding the biological and psychological basis of depressive disorders. Depressive disorders occur in approximately 15 to 25 percent of the population. Studies have found that 30 to 70 percent of all medical patients seen by physicians have depressive disorders in addition to their medical problems. Medical outcome studies have found that more than one half of these patients will not make significant improvement until their depression is recognized and treated. Depression appears to be inherited, although most people appear to inherit a vulnerability for depression. Approximately one half of all patients with depressive disorder have a close blood relative with depression. Studies of identical twins have shown that depressive disorder may occur with one twin but not the other. Most people become depressed purely from the impact of psychological, social or environmental influences. When people are overwhelmed and subjected to significant stress or loss, they can become depressed and stay depressed until they are treated.

Dealing with symptoms of depression requires an understanding as to whether the symptoms are a normal reaction, the result of a psychological disorder, or the result of a medical problem or condition. There are a number of medical conditions that can look and feel like depression. The symptoms associated with a psychological disorder or a medical condition are usually severe, unexplained, interfere with our ability to function, or prolonged.

Common Treatment Approaches

A large number of treatment strategies have been developed for the treatment of depression. Many of these approaches can be implemented individually, in groups or family therapy environment. There is considerable evidence to suggest that interventions which emphasize treatment of the family, and not the "identified patient", are critical to positive treatment outcome. Peer group approaches have been found to be effective for children. Play therapy is sometimes appropriate with younger children.

• Cognitive.  Cognitive approaches utilize specific strategies that are designed to alter negatively based cognition's. Depressed patients are trained to recognize the connections between their thoughts, feelings, and behavior; to monitor their negative thoughts; to challenge their negative thoughts with evidence; to substitute more reality-based interpretations for their usual interpretations; and to focus on new behaviors outside treatment.

• Behavioral.  Behavioral approaches designed to increase pleasant activities include several components such as self-monitoring of activities and mood, identifying positively reinforcing activities that are associated with positive feelings, increasing positive activities, and decreasing negative activities.

• Social Skills. Social skills training consists of teaching children how to engage in several concrete behaviors with others. Initiating conversations, responding to others, refusing requests, making requests, etc. Patients are provided with instructions, modeling by an individual or peer group, opportunities for role playing and feedback. The object of this approach is to provide the child with an ability to obtain reinforcement from others.

• Self-Control.  Self-control approaches are designed to provide the self-control strategies including self-monitoring, self-evaluation, and self- reinforcement. Depressive symptoms are considered to be the result of deficits from one or more areas and are reflected in attending to negative events, setting unreasonable self- evaluation criteria for performance, setting unrealistic expectations, providing insufficient reinforcement, and too much self-punishment.

• Interpersonal.  Interpersonal approaches focus on relationships, social adjustment and mastery of social roles. Treatment usually includes non-judgmental exploration of feelings, elicitation and active questioning on the part of the therapist, reflective listening, development of insight, exploration and discussion of emotionally laden issues, and direct advice.

• Medications.  Several class of medications are used with adult populations. Major types include monoamine oxidase inhibitors (e.g. phenelzine), tricyclics (e.g. imipramine and amitriptyline) and SSRIs (e.g. Prozac, Paxil, Zoloft, Serazone, Luvox), but other classes have emerged as well. These drugs are not without side effects. Very little is know about the long term impact of antidepressants on the health and development of children. All antidepressants can create and increased risk of suicidal behavior. Some carry an increased risk of aggressive behavior or violence. There definite as well as unpleasant side effects with nearly all antidepressants. Some medications that have been prescribed for years are now considered unsafe to prescribe to children. The risks and side effects of medications and the findings that competent therapy and counseling interventions may be more effective with less risk is restricting the use of medications with children.

In general, depression is very responsive to psychotherapy. Effective therapy must include an evaluation of the patient’s biological, psychological, social and cultural history. A treatment plan based on an evaluation is essential. Medications can be helpful, but the side effects of these medications and the potential for addiction in some medications must be considered and weighed against the potential benefits. In addition, nearly 2/3 of the studies show that antidepressants have no positive result in treating depression. Psychotherapy can be a very effective alternative to the use of medications. In most cases, there must be changes in the patient’s environment and social support system for treatment to be successful.

Families of people with depression often fail to see how they reinforce the disorder. They are often resistant to change despite expressed dedication of support and a desire to do whatever is necessary. Embarrassing or punishing a person who feels depressed will only make the disorder worse. There are effective and ineffective therapies. Unfortunately, effective therapies are often used incorrectly by well intended counselors and therapists. Competence, commitment as well as outstanding interpersonal qualities in a counselor or therapist are crucial for treatment to be successful.

Psychotherapy requires significant commitment where as treatment of depressive disorders with medication requires less effort. Since normal depression can improve over time and without therapy, a brief period of medication may not be of benefit.

Psychotherapy requires significant commitment where as treatment of depressive disorders with medication requires less effort. Since normal depression can improve over time and without therapy, a brief period of medication may not be of benefit. It is important for consumers to know when medications are more effective that psychotherapy. Psychotherapy can be helpful in cases of normal depression and can help insure the condition does not become chronic.

Antidepressant medications require a substantial period of time before they take effect and several trials of different medications may be necessary to find a medication that actually works. However, the use of medications require a substantial commitment for period of time up to 9 months. In some cases, a patient can terminate their medications after 6 to 9 months without a risk of relapse. Unfortunately there is no way to know if a person will relapse of not. Side effects are the primary reason why people stop taking their medications. The side effects of antidepressant medications can vary greatly and can have a significant or even traumatic impact on self-esteem and quality of life.

Psychotherapy is almost always the first treatment of choice while except in cases where depressive symptoms are so severe or critical that immediate relief is necessary to restore functioning and to prevent immediate and severe consequences. Medication is usually the second choice after a comprehensive and competent trial of psychotherapy. Combined use of medications and psychotherapy at the onset of treatment can confound evaluation of treatment effectiveness and the observed source of change. However, combined use in many cases produces a favorable result. It is harder in a combined medication and therapy approach to tell which approach is or is not helping and how much it is helping a specific child. However, research has found that combined psychotherapy and medication can be beneficial.

Psychotherapy, or the psychotherapist, can generally be considered ineffective if a trial of 3 months has not produced a measurable and noticeable improvement. A decision to change therapists or to start a medication may be necessary at this point. Several trials of psychotherapy or medications may be necessary to successfully treat depressive disorders.

The prognosis for treatment of depression is good. Positive treatment outcomes are primarily dependent on a correct diagnosis, and understanding of the etiology and implementing an appropriate intervention.

Programs & Interventions

• Outpatient Counseling or Psychotherapy. Usually involves hourly appointment for one or two days a week.  Duration of treatment can last 3 months to several years depending on the problem and treatment approach used.

• Medications.  Requires a minimum of 6 to 9 months commitment to medications. Long term reliance on that medication is often the result. Side-effects and increasing the dosage of medications is likely. substantial.

• Short Term Admission to a Psychiatric Hospital. Brief stays are normally focused on stabilizing severe problems and crises. Programs almost never address underlying problems or long term treatment issues that may be necessary for lasting or complete recovery. 

• Outpatient Day Treatment Program. Involves participation from 1 to 3 day a week in a program that is usually affiliated with a psychiatric hospital. Day treatment programs are usually a step down from a hospital and more intensive than outpatient counseling or psychotherapy.

• Residential Inpatient Treatment. Involves living is home or dormitory facility that may or may not be locked.  The programs can be have minimal structure or be highly structured. Residential program normally include routines that involve daily living activities, an educational or occupational program, as well as individual and group therapy.

• Outdoor Therapeutic Programs. Involves short term or longer term participation in wilderness and other outdoor settings that provide a variety of experiential and personal growth opportunities. These include personal and group challenges, activities that require initiative, outdoor sports, wilderness or survival education, exercise, nutrition, and separation from unhealthy environments. Healthy and therapeutic group interactions are facilitated and practiced.  Individual counseling and therapy is often a component of these programs.

Advice For Adults And For Parents Of Children Who May Have Depression

• Seek immediate advice and consultation from a crisis intervention specialist or a qualified health care professional if you or your chill have any of the serious and critical symptoms listed above.

• Seek advice and consultation as soon as possible from a qualified mental health professional if you or your child experience symptoms of depression that are severe, prolonged, debilitating, unexplained or unusual.

• Seek medical advice if you or your child have health problems, the symptoms are not explained and there has been no medical evaluation for their symptoms.

• Recognize the biological effects of alcohol use.  Avoid or minimize alcohol use. Alcohol is a depressant in which prolonged or excessive use will increase and deepen symptoms associated with depression. Alcohol can produce a "high" and initial relief from depression. Regular alcohol use, even in moderation, can prolong recovery and deepen symptoms of depression.

• Avoid drugs that are not medically appropriate or approved by a physician.

• Learn more about any medications you are taking. Ask a physician and pharmacist about potential interactions and side-effects. Know when medication are more effective that psychotherapy.

• A normal depression is usually temporary, can come and go, but should diminish over time.

• Maintain a regular and nutritional diet. Avoid meal skipping. A proper diet is a critical source of energy for you or your child's  ability to cope and recover.

• Maintain a regular sleep cycle. Avoid sleeping or napping during the day if it is difficult to sleep during regular times. Irregular sleep patterns prolong or worsen symptoms of depression.

• Children or adults should remain involved and avoid extended isolation from positive activities and influences.

• Maintain regular or routine physical activity that is appropriate for any existing medical problem or condition.

• Physical activity can help relieve and manage depression.

• Spend time with people who listen, understand, kind, respectful and can be firm.

• Create opportunities and take time on a regular basis to enjoy pleasurable activities and recreational interests.

• Be sure you research and understand the limits and problems involved when using mental health insurance.

Dated: December 30, 2007