Depression in Adolescence Depression in Adolescents

The link between symptoms, etiology, core biochemical processes, treatment outcome, and treatment response of affective (mood) disorders is yet to be adequately understood for allowing their categorization, such that it meets universal approval. Still, one has to make an attempt in this regard, and researchers propose a potentially-acceptable one, derived from extensive consultation.

In case of affective disorders, the basic disturbance is an affect (mood) change, typically extreme elation or depression (without or with related anxiety). An overall activity level change generally accompanies this change of mood, and a majority of other related symptoms either will be conveniently recognized in the context of these changes, or will be secondary to them. Most disorders have a tendency of repetition, and the commencement of individual bouts is usually linked to stressful circumstances or occurrences.

The key criteria of classification of affective disorders have been selected for practical purposes, in that, these criteria permit easy identification of common clinical problems. Single spells are distinguished from multiple-episode or bipolar disorders, as a considerable percentage of clients only experience a single episode of ailment. Severity is accorded importance owing to treatment implications as well as for implications for providing different service levels. Differentiating between different severity levels continues to be an issue -- the three levels (severe, moderate and mild) are specified because of their preference by 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 are:

1. Disturbed sleep;

1. Lowering of self-confidence and self-esteem;

1. Ideas of unworthiness and guilt (even in case of mild depression);

1. Acts or ideas of suicide or self-harm;

1. Pessimistic, hopeless views of future;

1. Diminished appetite; and

1. Decreased attention and concentration

The low mood does not vary much from one day to the next, and is typically unresponsive to situations, but may nevertheless display a distinctive diurnal change with the day's progress. As in the case of manic episodes, depression's clinical presentation depicts overt individual variations. Further, among adolescents, atypical presentations will be particularly common. In some instances, motor agitation, anxiety, and distress might sometimes be more pronounced, and added features like irritability, histrionic behavior, hypochondriac preoccupations, excessive drinking, and exacerbated pre-existing obsessional or phobic symptoms might disguise change of mood. For mild-to-severe bouts of depression, no less than a fortnight is needed for diagnosis; however, in case of abnormally severe symptoms and swift onset, shorter diagnosis periods might be reasonable.

Some symptoms might be evident and the patient might develop distinctive features recognized widely as possessing singular clinical significance. Of depression's "somatic" symptoms, the most characteristic examples include loss of pleasure or interest in normally enjoyable activities; waking earlier than usual from sleep (at least two hours early);

lack of any emotional reaction to ordinarily pleasurable events and surroundings;

weight loss (defined usually as a minimum of 5% body weight loss within a month); worse depression in the daytime; noticeable libido and appetite loss; and objective proof of certain psychomotor agitation or retardation (reported or remarked on by others).

Normally, this somatic disorder is not considered as present until at least four of the aforementioned symptoms are clearly found.

The mild-moderate-severe categorization of depressive episodes must only be utilized for the first bout. Any further spells that occur must be categorized under a subdivision of recurring depressive disorder. The above severity grades cover various clinical states psychiatrists come across in diverse kinds of practice. People suffering from mild depression commonly seek treatment at general medical and primary care settings, while psychiatric inpatient clinics mostly deal with people suffering from severe levels of depression (WHO, n.d.)

Severe depressive episode with psychotic symptoms

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), severe depressive conditions are defined as those conditions characterized by a sense of desolation, sorrow, and guilt; sleep disturbances; and loss of appeal in activities. In a majority of instances, people suffering from major depression also undergo significant weight change.

Acute depression has diagnosed across all age groups and is seen most commonly in females. There are many sound treatment options for depressive disorders, but if left untreated, severe depressive disorder may end in suicide by the patient (Sheaffer, 2016). According to DSM-5 conditions, adolescents or kids may be diagnosed as "depressed" if a minimum of five symptoms are found in a diagnostic period of two weeks; (1) irritable or depressed mood; (2) loss of pleasure or interest in conjunction with any 3 symptoms listed below:

Hypersomnia or insomnia
1. Considerable appetite or weight loss (over 5% of weight within a month's time)

1. Unenergetic or fatigued conduct

1. Psychomotor retardation/agitation

1. Indecisiveness or reduced concentration

1. Persistent thoughts of suicide or death and

1. Feelings of guilt or worthlessness.

Aside from the aforementioned DSM-5 conditions, teenagers and kids might also experience some symptoms listed below:

1. Constant irritable or sad mood

1. Feelings of boredom

1. Frequent non-specific and unclear physical complaints

1. Substance/alcohol abuse

1. Frequent truancy or weak academic performance

1. Recklessness

1. Increased anger, hostility, or irritability.

Symptoms bring about considerable functioning impairment or distress.

Depression Scales like Reynolds Adolescent Depression Inventory, Beck Depression Inventory, and Children's Depression Inventory may be employed for establishing baseline functioning, severity, and monitoring treatment progress (MDwise, 2010).

Case-

A white female, Anne, aged 16, was hospitalized at Bradley Hospital for suicidal ideations displayed 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 has a suicidal ideation history and has previously attempted to slash her skin, but self-reported that the blade she used wasn't penetrating her skin. Anne was concerned about the fact that she might not be capable of stopping herself the next time.

Roughly, 322 suicides were reported in 1994 in the U.S. among young teens and pre-pubertal kids (aged between 5 and 14 years), while about 4956 suicides were reported among older teens and young adults (aged between 15 and 24 years). Therefore, clearly, suicide risks increase appreciably at puberty. Such suicidal tendencies are linked strongly to acute dysthymia or depressive disorder, disruptive disorder, conduct disorder, schizophrenia, developmental disorder, and oppositional defiance. Further, a strong relationship exists between suicide and substance abuse in teenagers; however, the teen in question had no history of substance abuse (Sekhar, 2000).

Differential Diagnosis-

Depression's differential diagnosis covers a broad range of clinical disorders, including:

1. Endocrine disorders like hypothyroidism, hyperthyroidism, etc.

1. Diseases of the CNS (central nervous system) like multiple sclerosis, Parkinson's disease, neoplastic lesions, dementia, etc.

1. Sleep disorders

1. Drug-related problems such as cocaine abuse and CNS depressant side-effects

1. Infectious disease such as mononucleosis (Halverson, 1994-2016)

Diagnosis-

Anne reportedly suffers from depression since 2 years. Ever since her 8th grade, she is obsessed with dying. Anne is obese, forlorn-looking, exhibits weak social skills, and does not make proper eye contact. Her affect proved to be apathetic and flat. She reports irritability, appetite issues, sleeping issues, and decreased energy. She also confesses to a great sense of powerlessness, despair, and worthlessness. The above five symptoms suffice for making a diagnosis of severe depression.

MDD or major depressive disorder is projected to be occurring among 2% kids and between 4 and 8% of teenagers. In childhood years, it is found equally in females and males, but in adolescent years, its female-to-male ratio is 2:1. It often occurs together with dysthymia, a chronic condition of depression that takes place almost every day, among kids, for a minimum of one year. This fact is of significance, as early onset of dysthymia (before age 21) will make a person more susceptible to major depression.

Bradley hospital diagnosed Anne with "Axis I: Major Depressive Disorder Recurrent Severe with Psychotic Features" as well as "Axis V: Global Assessment of Functioning current 35 (the previous year's highest score was 75). While Axis II was not mentioned, she was diagnosed with learning disability as well. Anne is also asthmatic, and takes albuterol for it; however, this was not significant enough to include Axis III. Lastly, though not recorded, I feel the patient suffers from several environmental and psychosocial issues, which may be covered under Axis IV.

Furthermore, Anne was diagnosed with a psychotic disorder (which was not otherwise specified), dysthymia, and schizophrenia. As mentioned previously, dysthymia and MDD are often found to be comorbid with one another. Schizophrenia diagnosis is not easy in childhood. Auditory hallucinations, magical or irrational thinking, and delusions are suggested to be key diagnostic features. The patient confesses to being interested in witchcraft. She arrived for her appointment dressed in all black with black-painted fingernails. Adolescent schizophrenia may have a stealthy onset with the condition of apathy -- characterized by withdrawal and changes in sense of hygiene. Anne's chart depicted she was not showering properly (i.e., lack of self-care). Additionally, schizophrenia can co-occur with mental retardation, autism, learning disabilities, and conduct disorder. Anne has learning disability. Also, she has imaginary friends that aren't actually hallucinations since Anne actively mimics their voices. Anne reportedly has one auditory hallucination. Sufficient information is lacking to make…