Adults who work with young people are usually the first to recognize when a youth is changing for the worse. Too often, however, warning signs are not recognized until after the youth has killed himself or herself. It is critical that parents, teachers, pediatric health practitioners and other individuals look for and ask about these warning signs, so that youth with clinical depression can be referred for a formal mental health evaluation and treatment. Preskorn notes in one review by Robins that approximately 70% of adults who died by suicide saw their primary care physician within six weeks prior to the suicide. This underscores the need for practitioners to be able to recognize and refer youth who are depressed for mental health evaluation.
As noted previously, major depression is the most severe form of clinical depression, and the one that has the greatest impact on youth. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a major depressive episode is characterized by a change lasting at least two weeks, during which time an individual has become depressed or irritable, or has lost interest in most activities for most of the day, nearly every day. (Understand that the change may have occurred months or years ago, though not noted by the family.) The youth also experiences problems at home, in school, with peers or on the job and experiences at least five of the following symptoms nearly every day:
Depressed or irritable mood? look for:
Marked decrease in interest or pleasure in activities? look for:
- Directly and indirectly says "I hate my life"
- Easily irritated
- Rebellious behavior
- Seldom looks happy
- Frequent crying spells
- Wears somber clothes
- Listens to music or has themes in writing with depressive or violent undertones
- Hangs around friends who appear depressed or irritable
Significant change in appetite or weight? look for:
- Frequently says "I?m bored"
- Withdraws or spends much time in his or her bedroom
- Declining hygiene
- Changes to a more troubled peer group
Significant changes in sleeping habits? look for:
- Becomes a picky eater
- Snacks frequently and eats when stressed
- Quite thin or overweight compared to peers
Psychomotor agitation or slowing? look for:
- Takes more than an hour to fall asleep
- Multiple awakenings
- Wakes in the early morning hours and can?t return to sleep
- Sleeps more than normal
Fatigue or loss of energy? look for:
- Agitated, always moving around
- Mopes around the house or school
Feelings of worthlessness or inappropriate guilt? look for:
- Too tired to do schoolwork, play or work
- Comes home from school exhausted
- Too tired to cope with conflict
Decreased concentration or indecisiveness ? look for:
- Describes self as "bad" or "stupid"
- Has no hope or goals for the future
- Always trying to please others
- Blames self for causing divorce or a death, when not to blame
Recurrent thoughts of death or suicide? look for:
- Often responds "I don?t know"
- Takes much longer to get work done
- Drop in grades
- Headaches, stomachaches
- Poor eye contact
- Gives away personal possessions
- Asks if something might cause a person to die
- Wants to join a person in heaven
- Says "I?m going to kill myself"
- Actual suicide attempts
Note that most youth will experience at least one or two of these symptoms at various times. However, when several of these symptoms occur at the same time for two weeks or longer, the medical illness called clinical depression is likely affecting the youth. The youth should receive a formal evaluation for depression, which should then be treated once identified.
Families will also want to keep the following important points in mind when their child is being evaluated by a health practitioner:
1) Depression can involve suicidal and homicidal thoughts or actions and errors in judgment that endanger the youth or others. Sufficient steps must be taken to maintain the safety of the youth and others. All families should be asked about guns in the home; depressed youth tend to show poor judgment and should not have access to guns. Safety issues also need to be monitored on an ongoing basis by the health practitioner.
2) All youth seeing a health practitioner for any reason should be screened for possible depression. Health practitioners need to make sure that signs of irritability or withdrawal are not attributed to the youth?s "personality" when there are indications of clinical depression. This distinction is essential, as the youth will remain depressed and continue to have problems if these symptoms are incorrectly attributed to his or her personality (which will often wrongly imply to the practitioner that little can be done to improve the symptoms). Similarly, health practitioners need to make sure that signs of poor concentration and agitation are not incorrectly attributed to attentiondeficit/ hyperactivity disorder (ADHD), when indications of clinical depression are present. (Note that some youth will experience both clinical depression and ADHD.)
3) Consultation with school personnel is essential as this gives an important perspective on how the youth is doing academically and socially. If school personnel have not previously identified depression in youth, then, with parent or guardian permission, the clinician should discuss signs of depression with the school staff.
4) Co-occurring conditions, including ADHD, anxiety disorders and substance abuse, need to be evaluated as well. Co-occurring conditions are clearly the rule with clinical depression, not the exception.
5) It is normal for youth to become depressed after the loss of a family member or close friend. However, if the youth experiences significant problems at home, school or work, has significant suicidal thoughts, or stays depressed for more than two months, the depression is no longer normal and warrants a formal mental health evaluation and treatment.
6) A thorough physical exam by the primary care physician is an essential part of the evaluation for depression. This exam can help to optimize the health of the youth, rule out general medical conditions, and, if present, identify the direct physiological effects of substances such as alcohol or drugs. home, with peers, in the classroom, and/or on the job, and may die by suicide. "The blues" will only affect the youth?s mood and functioning briefly and generally does not result in suicidal thinking.
It is critical that
and other individuals
look for and ask
about these warning
signs, so that
youth with clinical
depression can be