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Depression in Boys and Adolescent Males

Only in the past two decades has depression in children been taken very seriously. Research has revealed that depression is occurring earlier in life today than in past decades. In addition, research has shown that early onset depression often persists, recurs, and continues into adulthood, and that depression in youth may also predict more severe illness in adult life. An NIMH sponsored study of 9 to 17 year olds estimates that the prevalence of any depressive disorder is more than 6 percent in a six month period, with 4.9 percent having major depression. Before puberty, boys and girls are equally likely to develop depressive disorders. After age 14, however, females are twice as likely as males to have major depression or dysthymia. The risk of developing bipolar disorder remains approximately equal for males and females throughout adolescence and adulthood.

The depressed younger child may say he is sick, refuse to go to school, cling to a parent, or worry that the parent may die. The depressed older child may sulk, get into trouble at school, be negative and grouchy, and feel misunderstood. Signs of depressive disorders in young people are often viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely label a young person with a mental illness diagnosis. However, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development. Depression in young people frequently co occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, as well as with other serious illnesses such as diabetes.

Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents, there is also an increased risk for substance abuse and suicidal behavior. Unfortunately, these disorders often go unrecognized by families and physicians alike.

Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that for adults, a number of recent studies have confirmed the short term efficacy and safety of treatments for depression in youth. An NIMH funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy is the most effective treatment. Additional research is needed on how best to incorporate these treatments into primary care practice.

Bipolar disorder, although rare in young children, can appear in both children and adolescents. The unusual shifts in mood, energy, and functioning that are characteristic of bipolar disorder may begin with manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the illness. Twenty to 40 percent of adolescents with major depression go on to reveal bipolar disorder within five years after the onset of depression.

Depression in children and adolescents is associated with an increased risk of suicidal behaviors. This risk may rise, particularly among adolescent males, if the depression is accompanied by conduct disorder and alcohol or other substance abuse. In 2002, suicide was the third leading cause of death among young males, age 15 to 24. NIMH supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may die by suicide in the young adult years. Therefore, it is important for doctors and parents to take seriously any remarks about suicide.

NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limitations on young peoples access to lethal agentsincluding firearms and medicationsmay hold the greatest suicide prevention value.

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Antidepressant Medications

There are several types of medications used to treat depression. These include newer antidepressant medicationschiefly the selective serotonin reuptake inhibitors (SSRIs)and older ones, the tricyclics and the monoamine oxidase inhibitors (MAOIs). The SSRIs (and other newer medications that affect neurotransmitters such as dopamine or norepinephrine) generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think it isnt helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects, pages 19 20) may appear before antidepressant activity does. Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, you should never discontinue your medication without first talking to your doctor. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.

Recently, concerns have been raised that the use of antidepressant medications themselves may induce suicidal behavior in youths. In fact, following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the FDA has adopted a black box label on SSRI medications to warn the public about an increased risk of suicidal thoughts (suicidal ideation) or behavior (suicidality) in children and adolescents treated with these medications. However, studies show that there are substantial benefits from medication treatment for adolescents with moderate and severe depression, including many with suicidal ideation. Parents and children should work with their health care provider to determine the best and most appropriate treatment.

Medications for depressive disorders are not habit forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, doctors must carefully monitor these treatments to determine if the patient is getting the most effective dosage. The doctor should check regularly the dosage of each medicine and its effectiveness.

For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, including many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis (a sharp increase in blood pressure) that can lead to a stroke. The doctor should furnish a complete list of prohibited foods, and the patient should carry it at all times. Other forms of antidepressants require no food restrictions. Efforts are underway to develop a skin patch system for one of the newer MAOIs, selegiline. If successful, this may be a more convenient and safer medication option than the older MAOI tablets.

Medications of any kind prescribed, over the counter, or borrowed should never be mixed without consulting a doctor. Health professionals who may prescribe a medication, such as a dentist or other medical specialist, should be told of all the medications the patient is taking. Some medications, although safe when taken alone, can cause severe and dangerous side effects if taken in combination with others.

Alcoholincluding wine, beer, and hard liquoror street drugs may reduce the effectiveness of antidepressants and should be avoided. However, doctors may permit people who have not had a problem with alcohol abuse or dependence to use a modest amount of alcohol while taking one of the newer antidepressants.

Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants, but they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are also not effective antidepressants, but they are used occasionally, under close supervision, in medically ill depressed patients.

Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this illness. Doctors must carefully monitor its use as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood stabilizing anticonvulsants, valproate (Depakote) and carbamazepine (Tegretol). Both of these medications have gained wide acceptance in clinical practice, and the Food and Drug Administration has approved valproate for first line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal), and topiramate (Topamax); however, their role in the treatment of bipolar disorder is not yet proven and remains under study.

Most people who have bipolar disorder take more than one medication. In addition to lithium and/or an anticonvulsant, doctors often prescribe a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Questions about any medication prescribed, or problems that may be related to it, should be discussed with your doctor.

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Psychotherapies

Several forms of psychotherapy, including some short term (10 20 weeks) therapies, can help people with depressive disorders. Two of the short term psychotherapies that research has shown to be effective for depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Cognitive behavioral therapists help patients change the negative thinking and behavior patterns that contribute to, or result from, depression. Through verbal exchange with the therapist, as well as homework assignments between therapy sessions, CBT helps patients understand their depression and resolve problems related to it. Interpersonal therapists help patients work through disturbed personal relationships that may be contributing to or worsening their depression. Psychotherapy is offered by a variety of licensed mental health providers, including psychiatrists, psychologists, social workers, and mental health counselors.

For many depressed patients, especially those with moderate to severe depression, a combination of antidepressant medication and psychotherapy is the preferred approach to treatment. Some psychiatrists offer both types of intervention. Alternatively, two mental health professionals may collaborate in the treatment of a person with depression; for example, a psychiatrist or other physician, such as a family doctor, may prescribe medication while a nonmedical therapist provides ongoing psychotherapy.

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Men and Depression

Researchers estimate that at least six million men in the United States suffer from a depressive disorder every year.3 Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.13

Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime; however, there is debate among researchers as to whether substance use is a symptom of underlying depression in men or a co occurring condition that more commonly develops in men. Nevertheless, substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.

Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harms way.

More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives. In addition to the fact that men attempt suicide using methods that are generally more lethal than those used by women, there may be other factors that protect women against suicide death. In light of research indicating that suicide is often associated with depression, the alarming suicide rate among men may reflect the fact that men are less likely to seek treatment for depression. Many men with depression do not obtain adequate diagnosis and treatment that may be life saving.

More research is needed to understand all aspects of depression in men, including how men respond to stress and feelings associated with depression, how to make men more comfortable acknowledging these feelings and getting the help they need, and how to train physicians to better recognize and treat depression in men. Family members, friends, and employee assistance professionals in the workplace also can play important roles in recognizing depressive symptoms in men and helping them get treatment.

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