Treatment

Mental Decline. Depression in the elderly is associated with a decline in mental functioning, regardless of the presence of dementia. Depression may be a predictor or even a cause of Alzheimer's disease. Brain scans in the elderly, for example, have reported greater atrophy in the brains of depressed individuals than in those of nondepressed ones.

Osteoporosis. Some studies have linked past and current major depression with bone-density loss in women. One explanation for this association is that depressed women have higher levels of the stress hormone cortisol, which may contribute to bone density loss.

Treating Depression in the Elderly

Some experts recommend only psychotherapy or attention intervention for elderly patients with mild depression. In many older patients, a regular exercise program may be sufficient to improve mood. Ideally, elderly people with more serious depression should be treated with a combination of psychotherapy and antidepressants on an ongoing basis, even after their depressive symptoms are relieved. A 2006 study of patients over age 70 indicated that the best way to prevent relapse is to continue antidepressant drug therapy for at least 2 years after the patient becomes symptom-free.

The use of antidepressants in the elderly is problematic:

• Tricyclics are as effective as, and less expensive than, SSRIs, but they have more side effects. Specifically, they pose a higher risk for adverse effects on the heart and possibly the lungs. (The older tricyclics, such as amitriptyline and imipramine, have other severe side effects in older adults.)
• SSRIs have fewer side effects than tricyclics. However, contrary to common belief, SSRIs do not appear to pose any lower risk for falls than the older tricyclic antidepressants. (The effect of the newer antidepressants on falling is not yet known.) In any case, patients with Parkinson's may want to avoid SSRIs because they can increase the risk for tremor and other symptoms of the disease.

Depression in Children and Adolescents

Depressed children often suffer in silence, and depression may be evident only from reports of problems in school. It is also often difficult for adults to believe that children can be chronically depressed. Symptoms for depression in children often differ from those in adults and may include the following:

• An inability to enjoy favorite activities
• Persistent sadness
• Increased irritability
• Complaints of physical problems, such as headaches and stomachaches
• Poor performance in school
• Persistent boredom
• Low energy
• Poor concentration
• Changes in eating and/or sleeping patterns
• A greater tendency to bully others -- anxious children are more often bullied.

Risk Factors for Depression in Children and Adolescents

Depression can occur in children of all ages, including preschoolers, although adolescents have the highest risk (about 20%). Risk factors for depression in young people include having parents, particularly mothers with depression. Early negative experiences and exposure to stress also pose a risk for depression. Sometimes depression develops after a physical illness. In adolescents, feeling alienated from parents is a strong predictor for depression.

Consequences of Depression in Children and Adolescents

Outlook for Future Emotional Problems. Adolescents who have depression are at significantly higher risk for substance abuse, recurring depression, and other emotional problems (such as bipolar disorder) in adulthood.

Risk for Suicide in Adolescents. Suicide is the third most common cause of death among adolescents, and is one of the most devastating events than can happen to a family. Suicide is most commonly associated with depression in young people but it is also linked with anxiety, psychosis, substance abuse, or impulsivity. More girls attempt suicide but more boys succeed, most often because they choose guns or violent methods while girls tend to overdose, which is more treatable. Nevertheless, attempts are major risk factors for a later suicide. Any expression of suicidal intent should be treated very seriously.

The following are danger signs in young people:

• Withdrawal from friends
• Sudden decrease in school performance
• Loss of interest in activities that were previously pleasurable
• Unusual irritability
• Unusual changes in sleep or eating habits

Risk factors for suicide include a history of neglect or abuse, history of deliberate self-harm, a family member who committed suicide (nearly always one who shared a common mood disorder), access to firearms, and living in communities where there have been recent outbreaks of suicide in young people. A romantic break-up is often the trigger for a suicidal attempt in teenagers. Feeling connected with parents and family protected young people with depression in one study, regardless of gender or ethnicity.

In one study, adolescents failed to seek help for suicidal thoughts for the following reasons:

• They believed nothing would help
• They were reluctant to tell anyone they had problems
• They thought it was a sign of weakness to seek help
• They did not know where to go

Parents should not hesitate to seek professional help for their children if they suspect they are thinking about killing themselves. This is a medical emergency and requires immediate treatment.

Behavioral therapies and antidepressants are promising treatments for preventing suicide but need study. There has been a decline in adolescent suicides over the past decade, which some experts attributed to the increased use of antidepressants in this population. However, recent evidence has indicated that antidepressants can indeed raise the risk for suicidality (suicidal thoughts and behavior). Children and adolescents who are prescribed antidepressant medication should be carefully monitored by both their parents and doctor, especially during the first few months of treatment, for any worsening of depression symptoms or changes in behavior. [See Suicide Risk and Antidepressant Medications in Treatment section.]

Treating Depression in Children and Adolescents

About 2% of American primary school-age children and 4 - 8% of adolescents suffer from depression. Studies suggest that when children or adolescents are treated, up to 80% recover. Still, 25 - 50% of these young people have a recurrence of depression within 2 years of their first episode of depression.

It is important to recognize that childhood depression differs from adult depression and that children may respond differently than adults to antidepressant medication. These variances are due to childhood brain development processes as well as age-related differences in drug metabolism. Children may experience medication side effects not seen in adults, and some antidepressants that are effective for adults may not work for children.

Mild-to-Moderate Depression. Children and adolescents with mild-to-moderate depression should receive psychotherapy before medications are tried. Cognitive therapy may be the best approach for children and adolescents with depression. (It may even be helpful in preventing depression in young people whose parents have a history of depression.) Some studies suggest that other types of psychotherapy, such as family therapy and supportive therapy, can also be very effective.

Severe Depression. The American Academy of Child and Adolescent Psychiatry recommends the SSRI antidepressants for children and adolescents with very severe depression that does not respond to psychotherapy. Tricyclic antidepressants do not tend to help adolescents and children and these drugs have many side effects. MAOIs are also not commonly prescribed.

Many SSRIs appear to be safe and effective, but at this time fluoxetine (Prozac) is the only one to be approved for children over age 7 and for adolescents. The FDA strongly advises against the use of specific SSRIs, such as paroxetine (Paxil), due to increased risk for suicidal behavior as well as the lack of any evidence supporting the drug's efficacy in pediatric patients.

For optimal results, SSRIs should be combined during the early acute phase with a mixture of psychotherapies, including cognitive-behavioral, interpersonal, and psychodynamic therapies. A 2004 study of adolescents with depression reported that combination treatment with fluoxetine and cognitive behavioral therapy was more effective than either treatment alone. Initial drug treatments should continue for at least 6 months, and a maintenance phase should last another year or longer.

The FDA is preparing a medication guide on the use of antidepressants in children and adolescents. Preliminary guidelines include the recommendation that caregivers and doctors be vigilant for any signs of suicidal intent or behavioral changes, particularly during the early phases of treatment, and that patients should see their doctor regularly after initiating drug therapy. [For more detailed information, see Suicide Risk and Antidepressant Medications.]