Psychobiological Depression in Childhood and Adolescence: a  clinical review

*Messina, L.F. , **Tiedemann, K.B.

REVIEW ARTICLE

*Psychology, Degree at Florida International University USA. Master's Degree in Neuroscience and Behavior at University of Sao Paulo- Brazil.

** Professor and Dr. Department of Psychology, University of Sao Paulo- Brazil.

Abstract

Objective: this study reviews clinical features, evolution, comorbidity and suicidal behavior in childhood and adolescence depression. Its objective is to provide clear information on this common, severe and not very easily recognized pathology.

Sources: literature searches were performed through Medline (1990-2004), with secondary-source follow-up.

Summary of the findings: scientific concern about depression in childhood and adolescence is recent and up to the 70Õs depression was considered rare or inexistent in this period. Current diagnostic systems define as basic features of depression in children and adolescents are the same ones found in adults for major depression episodes; however, researches emphasize the significance of the developmental process in the clinical manifestations, with predominant features in each phase.

Conclusions: nowadays, major depression in children and adolescents is understood to be a common, disabling and recurrent disease, with a high level of morbidity and mortality. It is an important public health problem.

 

Key words: psychobiological, major depression, childhood, clinical features.

Psychobiological Depression in Childhood and Adolescence: a clinical review

Lucinete de Freitas Messina and Klaus Bruno Tiedemann

Introduction

Depressive disorders consist of a group of pathologies with a high and growing prevalence in the general population. According to the World Health Organization, in the next two decades there will be a dramatic change in health needs of the world population, due to the fact that diseases like depression and cardiopathies are substituting the traditional problems of infectious diseases and malnutrition. The damage caused by diseases measured by the Disability Adjusted Life Years shows that major depression, the 4^th generative cause of overload in 1990, will be the 2nd cause in 2020, only losing to cardiac (Bahls 1999 and 2002;  Murray  & Lopez 1996).

Meanwhile, scientific interest in depression in children and adolescents is relatively recent, until the 1970s it was believed that depression in this age group was rare or even nonexistent (Bahls 2002;  Souza 1984). The National Institute of Mental Health in the U.S. (NIHM) officially recognized the existence of depression in children and adolescents in 1975, (Bhatara 1992) and the research on depression during these life phases has attracted a growing interest during the last two decades (Bahls, 2002; Kazdin & Marciano 1998; Olsson & von Knorring, 2002).

Many authors have called attention to the phenomena of depression in children and adolescents that not only is it now fully recognized, it seems to be more frequent and happening earlier and earlier (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, 1996). In the Los Angeles Epidemiologic Catchment Area Project study, according to Olsson and von Knorring, 1999; 25% of adults with major depression report that the first episode of the disease occurred before 18 years of age. In a recent review of the epidemiology of depressive disorder in children and adolescents found that the prevalence-year for major depression in children is 0.4 to 3.0%, and 3.3 to 12.4% in adolescents.

Major depression in childhood and adolescence is considered to exhibit a pervasive and long-lasting nature, affect multiple functions and cause significant psychosocial damage. The objective of this article is to present a review of depression in these age groups, emphasizing clinical status, its evolution, comorbidities and relation to suicidal behavior. For the purpose of this paper a search was done using these key words: depression, childhood and adolescence, clinical characteristics, in the period of 1990 to 2004, and a manual survey of bibliographic references.

Clinical status

Today depressive disorders in children and adolescents and those in adults are understood as the same phenomenological entities, a fact derived from studies which show the same diagnostic criteria reliably applied to these three age groups (Scivoletto, Nicastri , Zilberman, 1994; Shafii & Shafii 1992; .Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, 1996; Feij—, Saueressig, Salazar, Chaves, 1997;  Roberts, Lewinsohn, Seeley 1995).  According to the Diagnostic and Statistical Manual of Mental Disorders 1994 (DSM-IV) the basic symptoms of a major depressive episode (Table 1) are the same in adults, adolescents and children even though there are data suggesting that the predominance of characteristic symptoms can change with age, including very common symptoms in children (somatic complaints, irritability and social withdrawal) and symptoms less commonly found in children (psychomotor retardation, oversleeping and delusions). The International Classification of Diseases, 1993 (ICD-10) presently deals with depressive disorders in the same way for all age groups, with only the following specific citation Òatypical presentations are particularly common in depressive episodes in adolescenceÓ, but it does not supply more information.

 

Table 1 - Symptoms of major depressive episodes – DSM-IV

1. Depressed or irritable mood

2. Extremely diminished interest or pleasure

3. Significant weight loss or weight gain, or decreased or increased appetite

4. Insomnia or hypersomnia

5. Agitation or psychomotor retardation

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Diminished ability to think and concentrate, or indecisiveness

9. Recurrent thoughts of death, suicidal ideation, suicide attempt or plan

 

The majority of authors in the area of depressive disorders in childhood and adolescence cite that symptoms vary with age, emphasizing the importance of the maturation process at the different developmental stages of the symptoms and behaviors of depression, with one predominant symptomatological characterization per age (Shafii & Shafii 1992;  Kessler & Walters 1998; Versiani, Reis, Figueira 2000; Goodyer & Cooper 1993;  Sadler 1991).

Children

In preschool children (up to age 6 or 7) the most common clinical manifestations are physical symptoms, such as: pains (principally head and abdominal), fatigue and dizziness. Goodyer 1996 cites that approximately 70% of the cases of major depression in children present physical complaints. The complaints of physical symptoms are followed by anxiety (especially separation anxiety), phobias, psychomotor agitation or hyperactivity, irritability, loss of appetite with a failure to reach an adequate weight, and sleep disorders. Some authors also cite, with less frequency, the occurrence of enuresis and encopresis, sad facial expressions, deficient communication skills, frequent crying, repetitive movements and auto and heteroaggressiveness through aggressive and destructive behavior. The pleasure in playing or attending preschool diminishes or disappears and the acquisition of age-appropriate social skills does not occur naturally (Table 2) (Goodyer 1996;  Shafii & Shafii 1992; Souza 1984;  Ryan, Williamson, Iyengar, Orvaschel, Reich, Dahl, 1992; Versiani, Reis, Figueira 2000; Mirza, 1996). Although the majority of authors affirm that in this period suicidal ideation or attempts do not occur, Shafii & Shafii, 1992 emphasize that self-destructive behavior in the form of severe and repeated head bashing, biting oneself, swallowing dangerous objects and a propensity for accidents could be the suicidal equivalent in children that do not verbalize emotions. Meanwhile suicidal ideation in this age group is considered a rare occurrence, occurring only in special cases. North American studies of preschool children with depression found that often parents are also depressed and are involved in serious social problems (Versiani, Reis and Figueira 2000).

 

Table 2. 1. Pain (headache and stomachache)

2. Diminished pleasure in playing and going to school

3. Difficulty in acquiring age-appropriate social skills

4. Anxiety

5. Phobias

6. Agitation or hyperactivity

7. Irritability

8. Diminished appetite

9. Sleep disorders

 

In school-age children (between six or seven to twelve years of age) a depressive mood can be verbalized and what is often communicated is sadness, irritability or boredom.

They present a sad appearance, cry easily, have apathy, fatigue, isolation, decline in or poor school performance, which could result in school refusal, separation anxiety, phobias and death wishes. They may also report weak concentration, somatic complaints, weight loss, insomnia and mood-congruent psychotic symptoms (depreciative aural hallucinations and less frequently delusions of blame or guilt). The decline in performance could be due to weak concentration or interest, both characteristic of the state of depression. It is common for the child not to have friends, say that classmates do not like him/her or have an exclusive and excessive attachment to animals (Shafii & Shafii 1992; Souza 1984; Brent 1993; Pataki & Carlson 1995; Mirza 1996; Kashani, Rosenberg and Reid 1989).

Inability to enjoy oneself (anhedonia), poor relationship with peers and low self-esteem, describing oneself as stupid, silly or unpopular can also be present (Table 3). It is important to emphasize that teachers are often the first to notice the emerging modifications of depression in these children. In a study on school efficiency in nine to ten year old children with symptoms of depression, in one school in particular in the city of S‹o Paulo, state of S‹o Paulo-Brazil, Bandim, Roazzi and DomŽnech 1998 found that there was a significant decrease in school performance in all areas, principally in Portuguese and Sciences, when compared to children without depressive symptoms.

 

Table 3 - Depression symptoms in school age children

1. Sadness, irritability and/or dullness

2. Lack of ability to enjoy himself/herself

3. Sad appearance

4. Easy crying

5. Fatigue

6. Isolation with weak relationship with peers

7. Low self-esteem

8. Diminished or weak school performance

9. Separation anxiety

10. Phobias

11. Death desire or ideation

 

In both preschool as well as school-age children depression can become clear through observation of the themes of their fantasies, desires, dreams, games, with the predominant subjects of failure, frustration, destruction, injuries, losses or abandonment, blame, excessive selfcriticism and death  (Shafii & Shafii 1992).

Adolescents

The manifestation of depression in adolescents (from age 12) normally presents symptoms similar to those of adults, but there can exist important phenomenological characteristics that are typical of depressive disorder in this phase of life. Depressed adolescents are not always sad; they seem primarily irritated and unstable, and can have emotional outbursts and anger in their behavior. According to Kazdin and Marciano 1998 more than 80% of depressed youths present irritable mood and also loss of energy, apathy and marked lack of interest, psychomotor retardation, feelings of hopelessness and guilt, sleep disorders, especially oversleeping, appetite and weight changes, isolation and difficulty concentrating. Other unique characteristics of this group are poor school performance, low self-esteem, suicidal ideation and attempts, and serious behavior problems, especially abusive alcohol and drug use (Scivoletto, Nicastri, Zilberman 1994; Brent 1993; Ryan, Williamson, Iyengar, Orvaschel, Reich, Dahl, 1992; Versiani, Reis, Figueira 2000, Pataki & Carlson 1995, Kashani, Rosenberg, Reid 1989). The development of abstract thought around age 12 brings a clearer understanding of the phenomenon of death, consequently, both suicidal ideas and attempts, which are normally extremely fatal, reach a greater dimension in depressed adolescents, and so, adolescents are extremely vulnerable to them (Table 4). In a study on the symptoms of major depression in adolescents between the ages of fourteen and eighteen, in a community sample in the Oregon Adolescent Depression Project, in the US, Roberts, Lewinsohn,  Seeley 1995 found the most prevalent symptoms to be depressed mood, sleep disorders and difficulties in Table 2 - Depression symptoms in preschool children thinking (concentration problems and negative thinking) and the most stable symptoms to be depressed mood and anhedonia. Some authors as such as Sadler 1991 and  Baron & Campbell 1993 call attention to the difference between the manifestation of depression in female and male adolescents, emphasizing that girls report more subjective symptoms such as feelings of sadness, emptiness, boredom, anger and anxiety.

 

Table 4 - Depression symptoms in adolescents

1. Irritability and instability

2. Depressed humor

3. Loss of energy

4. Lack of motivation and significant lack of interest

5. Psychomotor retardation

6. Feelings of hopelessness and/or guilt

7. Sleep disorders

8. Isolation

9. Difficulty in concentrating

10. Poor school performance

11. Low self-esteem

12. Suicidal ideas and attempts

13. Severe behavioral problems

 

Girls normally are also more concerned with popularity, less satisfied with their appearance, more self-conscious and have lower self-esteem, while boys report more feelings of contempt, defiance and disdain, and show conduct problems like: missing classes, running away from home, physical violence, robberies and substance abuse. They emphasize that alcohol abuse can be a strong indicator of depression. As guidance for physicians, the following should not be considered normal, alerting to the probable presence of depression during adolescence: states of irritability or longlasting and/or excessive depression, prolonged periods of isolation from or hostility towards family and friends, distancing oneself from school or a significant decline in school performance, distancing oneself from group activities, and behaviors such as substance abuse (alcohol and drugs), physical violence, promiscuous sexual activity and running away from home (Sadler 1991). An adolescent is normally the best source of information as to his/her depressive suffering and his/her schoolmates and friends most easily notice the modifications caused by the pathology. Many authors emphasize that parents and teachers are often not aware of depression in their adolescent children and students.

 

Risk factors

The most important risk factor of depression in children and adolescents is the presence of depression in one of the parents, the existence of a family history of depression increases the risk by at least three times, followed by environmental stressors like physical and sexual abuse and loss of a parent, sibling or close friend (Shafii & Shafii 1992; Brent 1993; Lewinsohn, Rohde, Seeley, Klein, 2000). In a longitudinal study, involving 550 adolescent students between ages eleven and seventeen, Garrison, Jackson, Marsteller, McKeown and Addy 1990 in the US, concluded that at the start of adolescence, family environment is a more important predictor of depressive symptoms than stressful life events. Abou-Nazel,  Fahmy, Younis, El-Din, Fatah and Mokhtar 1991in Egypt, in a study with 1,561 adolescent students between ages eleven and seventeen, found that low academic performance is a marker for children at high risk of depression in this age group. Nunes, Dario  and  Paulucci. 1992 in a study in Londrina, state of Paran‡, Brazil, evaluated the presence of psychiatric disorders in the parents of individuals between ages seven and eighteen and found a predominance of mood disorders, especially major depression and dysthymia, confirming the importance of the family factor in vulnerability to depression in childhood and adolescents. Patten, Gillin, Farkas, Gilpin, Berry, Pierce 1997in a community study in California, US, with 5,531 adolescents between ages twelve and seventeen with depressive symptoms, concluded that a lack of the perception of support on the part of the parents is highly related to the presence of depressive symptoms in youths.

 

Evolution

On average, major depression in childhood increases around age nine and in adolescence between ages thirteen and nineteen. The first depressive episode usually lasts between approximately five and nine months. In terms of recovery, the majority of authors cite the article written by Kovacs, Feinberg, Crouse-Novak Paulauskas, Finkelstein 1984 in which 74% or cases presented significant improvement within a year, and 92% recovered in a period of two years (Kent, Vostanis, Feehan 1997;  Larsson, Melin, Breitholtz, Andersson 1991; Shafii & Shafii 1992; Kazdin & Marciano  1998; Garrison, Addy, Jackson, McKeown, Waller 1997; Olsson & von Knorring 1999; Pataki & Carlson 1995). Authors are unanimous in affirming that after recovery there normally remains some degree of psychosocial damage; and the earlier the appearance of the pathology, the greater the harm is likely to be, which was confirmed by the Rohde, Lewinsohn, Seeley 1994 study with 1,507 community adolescents in which they concluded that the early appearance of major depression is one of the most harmful forms of the disease and causes a more severe impact than in adults.

The risk of recurrence of major depression in childhood and adolescence is more frequent a few months after the first episode, with variable rates, between 33 and 80% in five years, according to review articles (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, 1996; Pataki & Carlson 1995; Mirza 1996). In longitudinal studies by Kessler & Walters 1998 and  Kovacs, Feinberg, Crouse-Novak Paulauskas, Finkelstein 1984 in the US and England, rates of recurrence between 60 and 74% were found. Children and adolescents with depression possess a high risk of recurrence which extends through adulthood, representing a high vulnerability to depressive disorders.

The following factors are predictive of recurrence: early onset, numerous previous episodes, the severity of the episode, presence of psychotic symptoms, presence of stressors, comorbidity (especially dysthymia) and not following treatment (Versiani, Reis, Figueira 2000). Some authors consider the appearance of a depressive episode in childhood and adolescence as predictive of bipolar disorder in the future, meanwhile there remains a lack of clear evidence regarding this relationship (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, 1996; Olsson & von Knorring 1999; Weissman, Wolk, Goldstein, Moreau, Adams, Greenwald 1999).

Comorbidity

Depressed children and adolescents normally present high rates of comorbidity with other psychiatric disorders, found more commonly than in depressed adults. The most common comorbidities in children are anxiety disorder (especially separation anxiety), conduct disorder, or oppositional defiance disorder and attention deficit disorder, and in adolescents, substance-related disorders and eating disorders (Kent, Vostanis, Feehan 1997; Olsson & von Knorring  2002; Kessler & Walters 1998; Pataki & Carlson 1995; Nolen-Hoeksema  & Girgus 1994; Rohde, Lewinsohn, Seeley 1994; Harrington, Bredenkamp, Groothues, Rutter, Fudge, 1994).  Goodyer and Cooper 1993 emphasize that depressive disorders in children and adolescents present 40% comorbidity with anxiety disorders and 15% with conduct disorders. Birmaher et al. 1996 describe major depression in Depression in childhood and adolescence: clinical features - adolescence as normally presenting an index of 40 to 70% psychiatric comorbidity, at least 20 to 50% of which have two or more comorbidities; and they emphasize that conduct disorders could persist after the depressive episode ends.

Kazdin and Marciano11 cite that depressed youths, in community studies, present average rates of comorbidity between 40 and 50% for at least one other psychiatric diagnosis, and can reach up to 80%. Martin and Cohen 2000 and Scivoletto et al. 1994  cite that 20% of depressed adolescents also present alcohol and drug abuse.

Kashani, Carlson, Beck, Hoeper, Corcoran, McAllister, 1987 in a community study of adolescents in the US, found the following rates of comorbidity among those with a diagnosis of major depression: 100% for dysthymia; 75% for anxiety disorders; 50% for oppositional defiant disorder; 35% for conduct disorder and 25% for substance abuse. Roberts, Lewinsohn,  Seeley 1995 in the US, in a community survey of 1,710 adolescents, found between sufferers of major depression the rate of 66% with a history of another mental disorder, and 34% with a previous depressive episode.

Garrison, Waller, Cuffe, McKeown, Addy, Jackson 1992 in the US, in a longitudinal epidemiological study with 3,283 participants between ages twelve and fourteen, researching dysthymia and major depression, found a high rate of comorbidity, in which 58% of those diagnosed with dysthymia also had major depression characterized by the presence of double depression. Also in the US, Kessler and Walters 1998 in an investigation of a population of 1,769 individuals between ages fifteen and twenty, which took part in the National Comorbidity Survey, found that 76.6% of those with major depression and 69.3% of those with dysthymia presented at least one other psychiatric disorder during their lives, and concluded that comorbidity for depression, in this age group, is more of a rule than an exception.

In relation to depression in childhood and adolescence, we know that the probability of comorbidities increases with the severity of the state of depression; in addition, its presence normally indicates a more severe evolution and a poorer prognosis (Bahls 2002; Shafii & Shafii 1992; Pataki & Carlson 1995).

 

Suicide

Child and adolescent suicide is a particularly dramatic and severe manifestation, and is the most relevant fact in the clinical status of depression. Today there is a tendency among authors to call a suicide attempt deliberate selfharm. (Prosser & McArdle 1996; Gunnell 2000; Hurry  2000). Suicidal behavior among youths has apparently been on the rise in the last decades, and adolescence is calling attention to itself as the period most related to death due to violent causes (Prosser & McArdle 1996; Patten, Gillin, Farkas, Gilpin, Berry, Pierce 1997; Weissman, Wolk, Goldstein, Moreau, Adams, Greenwald 1999; Gunnell 2000; Feij—, Salazar, Bozko, Bozko, Candiago, çvila, 1996; Lamb & Pusker 1991). In a study in England and Wales with individuals between ages fourteen and twenty four, according to Scivoletto et al. 1994 a 78% rise in suicide rates between 1980 and 1990 was found. Today suicide is the second cause of death among youths from ages fifteen to twenty-four in the US, according to the National Center for Health from 1986, as well as in England Statistics (Lamb & Pusker 1991), according to the study Office of Population Census and Surveys from 1990, and the suicide index in the general population for this age group is 0.01% (Harrington, Bredenkamp, Groothues, Rutter, Fudge, 1994).

In relation to age, suicidal ideation is common in schoolage children and in adolescents, however attempts are rare in children. Suicide attempts and ideation increase with age, becoming common after puberty. Of high-school students 4% presented one suicide attempt in the previous twelve months and 8% had already had one previous suicide attempt in their life, according to the United States Youth Risk Survey of Goodyer 1996 and Brent 1993 of 1990. And the indices of suicide ideation are even higher; community surveys found rates of 12 to 25% in primary school students and more than 25% in high school students (Brent 1993)

Weissman, Wolk, Goldstein, Moreau, Adams, Greenwald 1999 in the US, in a research follow-up study in a period between ten  and fifteen years with depressed adolescents, found a suicide attempt rate of 50.7% and 7.7% for suicides. In Brazil, Feij— et al. 1996 in an investigation of self-destructive behavior in adolescents in the range of thirteen to twenty years of age, accompanied suicide attempts attended at the Emergency Room of the Hospital de Cl’nicas de Porto Alegre-RS daily during a period of four months and found the following results: 88% were caused by overdose, 84.4% of the cases occurred in girls, 47% had already had a previous suicide attempt and 28% presented a diagnosis of major depression. Mirand and Queiroz 1991 researching on suicide ideation and suicide attempts in a sample of 875 medical students in Belo Horizonte, state of Minas Gerais, Brazil, obtained rates of 37% for suicide ideation and 2.3% for suicide attempts.

Approximately 80% of adolescent suicide attempts were through overdoses, followed by cutting wrists. Close to 65% of suicides are committed with guns, followed by hanging, jumps and overdoses. Shafii and Shafii 1992 cite a study in Louisville, US, in which 57% of the adolescent suicides were with guns, emphasizing that 82% of the cases had never had specialized help. The majority of adolescent victims commit suicide impulsively and are often found intoxicated (alcohol and drugs) at the time of death. Suicide is three to four times more common in boys as it is in girls, while suicide attempts are two to five time more common in girls (Scivoletto, Nicastri, Zilberman 1994; Brent 1993; Pataki & Carlson 1995; Sadler 1991;  Hurry  2000; Feij—, Raupp, John. 1999; Lippi, Pereira, Soares, Camargos. 1990). The following are considered risk factors for suicidal behavior in childhood and adolescence: age, presence of previous attempts, family history of psychiatric disorders (especially with suicide attempt and/or suicide), absence of family support, presence of a gun in the house, serious and/ or chronic physical disease, presence of depression and comorbidity with other conduct disorders, and substance abuse. The risk of suicidal behavior in depressed adolescents is three times higher in the presence of these comorbidities (Pataki & Carlson 1995; Mirza 1996; Gunnell 2000; Feij—, Salazar, Bozko, Bozko, Candiago, çvila, 1996;Miranda &  Queiroz 1991; Lippi, Pereira, Soares, Camargos. 1990). A previous suicide attempt is the best predictor, so we calculate that 25% of adolescents who attempt suicide and 25 to 40% of youths who commit suicide have already had at least one previous suicide attempt. It is estimated that up to 11% of adolescents who Depression in childhood and adolescence: clinical features - attempt suicide through overdose will commit suicide in the following years (Hurry  2000). The feeling of hopelessness is strongly associated with suicidal behavior and predicts future attempts (Scivoletto, Nicastri, Zilberman 1994; Feij—, Saueressig Salazar, Chaves 1997; Lamb & Pusker 1991; Pfeffer 1992).  It is known that at least 50% of adolescents who commit suicide made threats or attempts in the past, and the risk of repeating an attempt is greater in the first three months after a suicide attempt (Brent 1993).

Precipitators of suicidal behavior in this age group are: losses, interpersonal crises with family or friends, psychosocial stressors, physical and sexual abuse, legal or disciplinary problems and exposure to the suicide of friends, relatives or even through the media (Scivoletto, Nicastri, Zilberman 1994; Brent 1993; Pataki & Carlson 1995; Hurry  2000; Feij—, Raupp, John 1999; Pfeffer 1992).  Knowing the risk factors associated with triggering factors provide the clinician with a necessary and useful indication of those statuses that need urgent specialist referral.

 

Conclusions

The study of depressive disorders in childhood and adolescence has already shown that their presence is sufficiently common and serious to deserve clinicians and researchersÕ attention. Especially if we consider the possibility suggested by modern epidemiological studies of their growing prevalence and earlier onset. The clinical manifestations of depression in children, adolescents and adults are essentially the same, to such an extent that the principal systems of classification of mental disorders use the same diagnostic criteria in these three life phases. There exists, however, a need to emphasize the relevance of unique characteristics of each phase of pediatric development, which model the clinical manifestations of depression, with predominant symptomalogical groups in the different age groups.

It is necessary to emphasize that depressive disorder has a heterogeneous presentation from childhood, requiring careful diagnostic evaluation by professionals involved with children and adolescents. Whether in relationship to the symptomatology or to the evolution, the existence of comorbid psychiatric pathologies brings a special complication to the study of pediatric depressions, as the coexistence of multiple diagnoses is more of the rule than the exception. Especially in these periods, it is necessary to consider the importance of using many sources of information (parents, teachers, friends) and establishing a clinical investigation.

In adolescents, there is today an understanding that major depression is common, debilitating and repeatable, involving a high degree of morbidity and mortality especially through suicide, which is one of the principal preoccupations of public health (Brent 1993; Pataki & Carlson 1995; Mirza 1996; Patten, Gillin, Farkas, Gilpin, Berry, Pierce 1997). We call attention to the fact that a vast majority of depressed children and adolescents do not wish to be identified and even less referred to treatment. In a study by Goodyer and Cooper 1993 in England, none of the adolescents identified as having major depression had been referred to treatment or was being treated. Depression in childhood and adolescence: clinical features.

In conclusion, depression in childhood and adolescence becomes particularly important when the question of suicidal behavior is considered. There even exist reports of suicidal behavior and suicide in preschool children, and its occurrence in adolescence is rising (Shafii & Shafii 1992). We estimate that depression is responsible for the majority of suicides in youths, reaching values close to 10% in cases of major depression. Today we know, in a relatively sure way, the risk factors as well as the triggering factors of suicidal behavior in children and adolescents, which permit better strategies of addressing the problem. And if we continue to consider depression, due to its usually satisfactory therapeutic result, as the principal preventable cause of suicide, there is much to be done, protecting and impeding innumerable potential victims of suicidal behavior caused by depressive disease.

 

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Corresponding author:

Lucinete de Freitas Messina

Rua Antonio Frederico Ozanan 1825 -Piracicaba -S‹o Paulo

CEP 13423000 – Piracicaba, SP, Brazil

Tel./Fax: +55 1934112088

E-mail: lfremess@usp.br

First Published: June 2nd 2006

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