• It comes under the broad category of
affective and emotional disorders of
childhood & adolescents
• Includes childhood depression, anxiety
disorders, adjustments disorders, PTSD &
• Childhood depression widely vary from adult
• Difficult to treat when suicidal ideations exist.
adolescence with estimates in preadolescents of the order of 0.5-2.5%
increasing up to 8% in adolescents.
• Recurrence of depression within 5 years is
• 50% developed to have recurrent
depression in the adulthood
• After 15 yrs, girls are twice more risk than
boys to develop depression.
• Depression is associated with high risk of suicidal behavior
• For every fatality there are at least 100 attempts.
• Suicidal risk is high with depressed boys who have comorbid disorders such as CD or SUD’s
• Among adolescents who develop MDD, 7% may commit
suicide (NIMH report-1997).
• 2% of high school students have made suicide attempts
that have come to medical attention, with larger numbers
making less serious attempts (Indian Report).
• Completed suicide occurs in about 1/100 000
preadolescents and 13/100 000 adolescents, with boys
exceeding girls by 4 to 1.
• Biomedical factors
Chronic illness (e.g., diabetes)
Hormonal changes during puberty
Parental depression or family history of depression
Presence of specific serotonin-transporter gene variant
Use of certain medications (e.g., isotretinoin [Accutane])
• Psychosocial factors
– Childhood neglect or abuse (physical, emotional, or sexual)
– General stressors including socioeconomic deprivations
– Loss of a loved one, parent, or romantic relationship
• Other factors
Attention-deficit/hyperactivity, conduct, or learning
History of depression
Clinical features of depression
• Sad mood or loss of interest or pleasure.
• Loss of weight, marked change in sleep pattern,
loss of appetite.
• Psychomotor agitation or retardation (inability to sit
still, temper tantrums or inability to get started are
• Reduction in energy levels, fatigue, and boredom.
• Feelings of worthlessness or guilt (in children and
young people this is usually attributed to what
others think of them).
• Continues ….
• Impaired thinking, concentration or
decision making with deterioration in
schoolwork and school refusal.
• Anhedonia (an inability to enjoy
• Social withdrawal.
• Combativeness with parents.
• Loss of interest in schoolwork.
• Delinquent behaviour.
• Recurrent thoughts of death or suicide.
• Psychotic depression
– Associated with apparent loss of reality
– Delusions or hallucinations, with a depressive
and self-critical or self punitive content, are
• Bipolar disorders
– Occasional elevation in mood status such as
excitability, irritability, excess energy, lack of
judgment, and disinhibition.
Normal reactive feelings of sadness
Medical disorders such as epilepsy, systemic lupus
erythematosus, traumatic brain injury, space occupying lesion,
endocrinopathies, and dementias
• Adverse drug reactions, for example clonidine, stimulants and
• Substance abuse (in particular ecstasy, amphetamines,
barbiturates, and cocaine)
Risk factors for completed suicide and
Suicidal ideation and/or
• Previous suicide attempt
• Major or minor depressive
• Substance abuse
• Antisocial behaviour
• Undesirable life events
• Problems with
parents, partners, school, or
work Loss in males
• Sexual or physical abuse
Previous suicide attempt and
Familial psychiatric disorder and
completed suicide attempt.
Alcohol or drug abuse
(particularly in males)
Acute life crisis
Disciplinary crisis/dispute with
friend or parent
Legal or disciplinary problems in
Warning signs for suicide behaviour
– In short term;
Thoughts of suicide as a solution to a problem
References to suicide in conversation
Disciplinary crisis or expulsion from school
Preparation in the form of writing a will or a final
Increase in help seeking behaviour
Improvement of mood directly beforehand
During the early stages of treatment the patient is
particularly vulnerable to suicide
Recurrence of a situation that preceded a previous
attempt of self-harm
– In longer term;
• Psychiatric morbidity
• Previous suicide attempts of patient or parent
especially when accompanied by a strong desire
• Recent losses
• Lack of confiding friend and isolation
• Learning disorder or academic underachievement
• History of violent or impulsive behaviour
• Social disadvantage: broken home, unwanted
pregnancy, conflict with parents, sexual, and
physical or emotional abuse.
– Sexually abused girls are 20 times more likely and sexually
abused boys 40 times more likely to commit suicide
• Encourage the child to avoid;
– Alcohol, illegal drugs, sleep deprivation,
academic & work pressure, or pretending that
nothing is wrong.
• Encourage the parents to avoid;
– Psychological cause hunting
• The first line drugs used are selective
serotonin reuptake inhibitors & the new
reversible monoamine oxidase inhibitors
• SSRIs are on the whole well tolerated and
present minimal danger in overdose
• Second line medications include venlafaxine
• TCA’s are not recommended for the
treatment of depression in this age group as
they are less effective, have unpleasant side
effects, and are dangerous in overdose
• Interpersonal: relieve symptoms through
resolution of interpersonal problems and
improved social adaptation (role playing)
• Analytic: personality reorganization,
adoption of mature defences, realistic sense
of self and resolve past traumas if any
(development of transference relationships
which helps in the development of insight.
• Play: to understand wishes, fantasies &
traumas. Discharging feeling via physical
• Behavioral: reduced positive
reinforcement from environment which
produces stimulus for depression
(modeling/shaping for appropriate prosocial behavior)
• Family: positive reframing decrease
blaming and scapegoating, altering
unhealthy family rules, recognizing crossgenerational dynamics.
• School based: diagnose & address spl
needs rltd to language or learning
difficulties, social inadequacies, etc. by
altering class room envmnt or mode of