“William” (fictional) was a 10-year-old boy whose behavior changed over the course of several months. In the previous year, his parents had divorced, he had moved to a new town, and started a new school. He lived with his mother during the week and his father on weekends. He became grumpier each day. Things that never bothered him before now got on his nerves. He started getting into fights with kids at school. He told his mother that “no one liked” him. His grades dropped after he stopped doing his homework. He dropped out of soccer and started spending most of his time in his room. He began breaking household rules. When his mother tried to correct him, he would start crying and say things like, “I hate you,” or, “I wish I was dead.”
William illustrates how depression might look in a child. Depression is more than ordinary sadness. Everyone is sad sometimes. After the death of someone we love, for example, we might be very sad for a very long time, but we should still be able to function in important ways. For human beings, important parts of life are relationships with family and friends, work or school, and play. A depressed adult might have trouble with his or her job, whether working in an office or taking care of a home. S/he might spend less time with family or friends, and/or be crabbier and more irritable around them. Adults who are depressed often look depressed- their faces look sad, they feel sad, and they often cry. They often described a “choked-up” feeling in their hearts.
Severe depression is extremely painful on the inside. Sufferers might be so agitated and anxious that they can’t keep still. Severely depressed people can become delusional and hallucinate– for example, they may feel a bad odor is coming from their bodies because they are rotting inside. Depression can be so painful that sufferers want to commit suicide, similar to patients with severe cancer who want to die to escape the pain.
Rarely, adults become so severely depressed that they no longer look depressed – their faces are restricted and show no emotion at all. They can become so shut down that they are barely functioning at all, unable to eat or sleep. At this stage, they might wish to die, but not have the energy to carry out a plan. They are most at risk for committing suicide in the early stages of treatment, when they have gained just enough energy to carry out a plan, but have not yet gained back the hope to see that their lives can improve. People who do not believe that depression is a medical condition have not spent much time with severely depressed people. Depression clearly affects their bodies and minds. It causes more health problems and disability than does cancer.
Depression looks and feels different in a child. (This is probably why health professionals used to believe that children could not get depressed – now we know that even preschoolers can become depressed.) A depressed child is more likely to be irritable than sad, becoming easily frustrated at minor mishaps. Children, especially before adolescence, often have difficulty identifying their feelings and are more apt to act mad than say they are sad. Friendships and schoolwork, major parts of the life of a child, are what tend to suffer. Children can be so depressed that they wish they were dead, but they usually do not try to hurt themselves.
A Major Depressive Episode is a period of at least 2 weeks in which there are at least 5 of the following symptoms occur most of the day, nearly every day: depressed mood, decreased energy, concentration, or interest in almost all activities, appetite or weight changes when not trying to diet, insomnia or hypersomnia (sleeping too much), psychomotor agitation or retardation, feelings of worthlessness or guilt, and/or recurrent thoughts of death. At least one of the symptoms must be either depressed mood or loss of interest. Children and adolescents can have irritable instead of depressed mood, and failure to gain appropriate weight rather than weight loss. Symptoms must not be due to the biological effects of a substance (such as a medication or recreational drug) or medical condition, or be due to bereavement. Clinicians add various features to the diagnosis of Major Depression, such as whether it is a single or repeated episode, whether it is mild, moderate, severe, or whether it has partially or fully remitted (has improved to the point where it no longer meets the definition for depression).
Persistent Depressive Disorder (formerly known as Dysthymia) is a milder but more chronic form of depression. There must be depressed mood most of the day, for most days, for a period of at least two years for adults and one year for children or teenagers. There must also be at least 2 of the following symptoms: increased or decreased appetite or sleep, decreased energy, low self-esteem, poor concentration or indecision, and/or feelings of hopelessness. Symptoms must not be better explained by Major Depression or be due to the biological effects of a substance or medical condition. Persistent Depressive Disorder is typically not as impairing as Major Depression, but may be more difficult to treat. Symptoms tend to wax and wane, depending on current stressors Cognitive Behavioral Therapy is a particularly important treatment for Persistent Depressive Disorder, since “doom and gloom” cognitive distortions are often associated with it.
Some people have what is termed “double depression”- a more severe Major Depression superimposed onto chronic milder depression. A person with chronic depression may not be able to cope with stressful events, make decisions and feel things will never work out. Major Depression may develop as a result. Often, the Major Depression resolves with medication, but the mild chronic depression remains. Persistent Depression can improve with antidepressants, but may be more difficult to treat. Medication treatments for chronic depression are less well-studied than for Major Depression.
Because depressed children are often irritable, a new category was added to added to the Depression category of the DSM V (a classification system for psychiatric conditions), called Disruptive Mood Dysregulation Disorder. Such children have severe and recurrent temper outbursts disproportionate to the situation. Between outbursts, they are mostly irritable or angry, most of the day, nearly every day for at least one year. Because these children are “moody,” in the past they were often mistakenly diagnosed with Bipolar Disorder and given stronger medication than they needed. When these children grew up they tended to be diagnosed with depression or anxiety disorders, which improved with antidepressant medication and psychotherapy.