This paper examines depression in adolescents through a combination of clinical overview and detailed case analysis. It begins by defining affective disorders and outlining the WHO classification of depressive episodes by severity. The paper then applies DSM-5 diagnostic criteria to a clinical case involving a 16-year-old female hospitalized for suicidal ideation, exploring her differential diagnosis, psychosocial history, familial influences, and cultural considerations. Treatment approaches discussed include cognitive behavioral therapy, antidepressant pharmacotherapy—specifically SSRIs—antipsychotic medications, and family-based psychoeducational interventions. The paper concludes by emphasizing the need for further research into childhood and adolescent depression treatment.
The link between symptoms, etiology, core biochemical processes, treatment outcome, and treatment response of affective (mood) disorders is yet to be adequately understood to allow for categorization that meets universal approval. Still, an attempt must be made in this regard, and researchers propose a potentially acceptable framework derived from extensive consultation.
In the case of affective disorders, the basic disturbance is a change in affect (mood), typically extreme elation or depression, with or without related anxiety. An overall change in activity level generally accompanies this mood change, and a majority of other related symptoms will either be recognized within the context of these changes or will be secondary to them. Most disorders have a tendency toward repetition, and the commencement of individual bouts is usually linked to stressful circumstances or events.
The key criteria for classification of affective disorders have been selected for practical purposes, in that they permit easy identification of common clinical problems. Single spells are distinguished from multiple-episode or bipolar disorders, since a considerable percentage of clients experience only a single episode of illness. Severity is accorded importance owing to its treatment implications as well as for providing different service levels. Differentiating between severity levels remains an ongoing challenge — the three levels (severe, moderate, and mild) are specified because of their preference among many clinicians (WHO, n.d., p. 94).
Typically, in severe, moderate, and mild depressive episodes, the patient normally experiences a depressed mood, reduced energy, and loss of enjoyment and interest, resulting in diminished activity and increased fatigability. One common symptom is noticeable tiredness following minimal effort. Other symptoms that commonly occur include:
The low mood does not vary much from day to day and is typically unresponsive to circumstances, but may nevertheless display a distinctive diurnal variation as the day progresses. As with manic episodes, the clinical presentation of depression shows marked individual variation. Among adolescents in particular, atypical presentations are especially common. In some instances, motor agitation, anxiety, and distress may be more pronounced, and additional features such as irritability, histrionic behavior, hypochondriac preoccupations, excessive drinking, and exacerbated pre-existing obsessional or phobic symptoms might obscure the underlying mood change. For mild-to-severe depressive episodes, a minimum of two weeks is required for diagnosis; however, in cases of abnormally severe symptoms and rapid onset, shorter diagnostic periods may be reasonable.
Some patients may develop distinctive features recognized as having particular clinical significance. The most characteristic examples of depression's "somatic" symptoms include:
This somatic syndrome is generally not considered present unless at least four of the aforementioned symptoms are clearly identified.
The mild-moderate-severe categorization of depressive episodes should be used only for the first episode. Any subsequent episodes should be categorized under a subdivision of recurring depressive disorder. These severity grades cover the various clinical states that psychiatrists encounter across diverse settings. People suffering from mild depression commonly seek treatment at general medical and primary care settings, while psychiatric inpatient clinics mostly deal with those suffering from severe depression (WHO, n.d.).
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), severe depressive conditions are characterized by a sense of desolation, sorrow, and guilt; sleep disturbances; and loss of interest in activities. In a majority of cases, people suffering from major depression also undergo significant weight change.
Acute depression has been diagnosed across all age groups and is seen most commonly in females. There are many effective treatment options for depressive disorders, but if left untreated, severe depressive disorder may end in suicide (Sheaffer, 2016). According to DSM-5 criteria, adolescents or children may be diagnosed as depressed if a minimum of five symptoms are present over a two-week diagnostic period, including either (1) irritable or depressed mood or (2) loss of pleasure or interest, along with any three of the following symptoms:
Aside from the aforementioned DSM-5 criteria, teenagers and children might also experience:
These symptoms must bring about considerable functional impairment or distress. Depression scales such as the Reynolds Adolescent Depression Inventory, Beck Depression Inventory, and Children's Depression Inventory may be employed for establishing baseline functioning, measuring severity, and monitoring treatment progress (MDwise, 2010).
A white female patient, aged 16, was hospitalized for suicidal ideation manifested through an attempt to slit her wrist with a knife. She was also reported to have considered hanging herself using a phone cord. The teenager had a history of suicidal ideation and had previously attempted to cut her skin, but self-reported that the blade she used had not penetrated the skin. She was concerned that she might not be capable of stopping herself the next time.
Approximately 322 suicides were reported in 1994 in the United States among young teens and pre-pubertal children (aged 5 to 14 years), while approximately 4,956 suicides were reported among older teens and young adults (aged 15 to 24 years). Suicide risk therefore increases appreciably at puberty. Such suicidal tendencies are strongly linked to acute dysthymia or depressive disorder, disruptive disorder, conduct disorder, schizophrenia, developmental disorder, and oppositional defiance. A strong relationship also exists between suicide and substance abuse in teenagers; however, the patient in question had no history of substance abuse (Sekhar, 2000).
Depression's differential diagnosis covers a broad range of clinical disorders, including:
The patient reportedly suffered from depression for two years. Since eighth grade, she had been preoccupied with thoughts of dying. She was obese and forlorn-looking, exhibited weak social skills, and did not make proper eye contact. Her affect was apathetic and flat. She reported irritability, appetite issues, sleep disturbances, and decreased energy. She also expressed a profound sense of powerlessness, despair, and worthlessness. These five symptoms were sufficient for a diagnosis of severe depression.
Major depressive disorder (MDD) is estimated to occur in approximately 2% of children and between 4% and 8% of teenagers. In childhood, it occurs equally in females and males, but in adolescence, the female-to-male ratio is 2:1. MDD often co-occurs with dysthymia, a chronic form of depression occurring nearly every day, for a minimum of one year in children. Early onset of dysthymia (before age 21) increases a person's susceptibility to major depression.
The patient was diagnosed with "Axis I: Major Depressive Disorder Recurrent Severe with Psychotic Features" and "Axis V: Global Assessment of Functioning — current score 35 (previous year's highest score was 75)." While Axis II was not formally noted, she was also diagnosed with a learning disability. The patient was asthmatic and took albuterol for it; however, this was not considered significant enough for an Axis III notation. Additionally, though not formally recorded, the patient was assessed as experiencing several environmental and psychosocial issues that could be covered under Axis IV.
Furthermore, the patient was diagnosed with a psychotic disorder (not otherwise specified), dysthymia, and schizophrenia. As previously noted, dysthymia and MDD are often comorbid. Diagnosing schizophrenia in childhood is not straightforward; auditory hallucinations, magical or irrational thinking, and delusions are considered key diagnostic features. The patient expressed an interest in witchcraft and arrived for her appointment dressed entirely in black with black-painted fingernails. Adolescent schizophrenia may have a stealthy onset, characterized by apathy, social withdrawal, and changes in personal hygiene. The patient's chart indicated she was not maintaining proper hygiene (i.e., lack of self-care). Additionally, schizophrenia can co-occur with intellectual disability, autism, learning disabilities, and conduct disorder — all of which had some relevance to this case.
The patient also reported having imaginary friends that were not, strictly speaking, hallucinations, since she actively mimicked their voices while remaining aware they were imaginary. She did report one auditory hallucination. Sufficient information was lacking to make a definitive strong diagnosis — a common situation in the early stages of the condition (Sekhar, 2000).
"Family history, environment, and cultural influences"
"CBT, SSRIs, and medication management strategies"
"Antipsychotic evidence and family-based interventions"
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