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Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis

Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis
Author:
Liza Bonin, PhD
Section Editor:
David Brent, MD
Deputy Editor:
David Solomon, MD
Literature review current through: May 2024.
This topic last updated: Sep 13, 2022.

INTRODUCTION — Depressive disorders are common in children and adolescents [1,2], impair psychosocial functioning, and are often accompanied by comorbid psychopathology [3,4]. Despite its detrimental effects, pediatric depression is often undertreated.

The epidemiology, clinical manifestations, assessment, and diagnosis of pediatric depression are reviewed here. Treatment of depression in youths is discussed separately. (See "Overview of prevention and treatment for pediatric depression" and "Pediatric unipolar depression and pharmacotherapy: General principles" and "Pediatric unipolar depression and pharmacotherapy: Choosing a medication" and "Pediatric unipolar depression: Psychotherapy".)

EPIDEMIOLOGY

Prevalence — The risk for depression increases during childhood [5]. As an example, a survey of more than 78,000 parents in the United States in 2007 found that among their children, the point prevalence of depression for different age groups was as follows [2]:

3 to 5 years – 0.5 percent

6 to 11 years – 1.4 percent

12 to 17 years – 3.5 percent

The one year and lifetime prevalence rates of depression are even higher. A survey of adolescents age 12 to 17 years in the United States (n >45,000) in 2010 and 2011 found that the one year prevalence of major depression was 8 percent [2]. Another study found that the lifetime prevalence in adolescents was 11 percent [6].

Sex ratio — The ratio of adolescent females to males who develop major depression is approximately two to one [6], which is similar to the ratio in adults [7]. This sex difference emerges during puberty; in adolescence, the risk for developing depression is greater in girls than boys [8]. In the United States, a study of adolescents age 12 to 17 years (n >45,000) found that the lifetime prevalence rates of major depression in females and in males were 18 and 8 percent [2].

However, in prepubertal children, depression appears to be more common in boys than girls. A meta-analysis of 12 community studies (n >15,000 children age ≤12 years) found that the estimated prevalence of unipolar major depression was 60 percent higher in boys than girls (odds ratio 1.6, 95% CI 1.1-2.4) [9].

Risk factors — Risk factors for onset of pediatric depression include [1,3,5,10-28]:

Low birth weight

Family history of depression and anxiety in first-degree relatives (including antenatal or postpartum maternal depression)

Family dysfunction or caregiver-child conflict

Exposure to early adversity (eg, abuse, neglect, or early loss)

Psychosocial stressors (eg, peer problems and victimization [bullying], and academic difficulties)

Gender dysphoria or identification as LGBTQ+, especially if youth is bullied

Negative style of interpreting events and coping with stress

History of anxiety disorders, substance use disorder, learning disabilities, attention deficit hyperactivity disorder, and oppositional defiant disorder

Traumatic brain injury

Chronic illness, especially if symptom and/or treatment burden yields chronic life disruptions

CLINICAL FEATURES — The clinical manifestations of depression include symptoms, functional impairment, and comorbid psychopathology.

Symptoms — Symptoms of pediatric depressive disorders include [29]:

Depressed or irritable mood – Depressed mood, such as feeling low, down, sad, or blue much of the time, is a cardinal symptom of depressive disorders. Patients may manifest a depressed mood by perceiving others as antagonistic or uncaring, brooding about real or potentially unpleasant circumstances, maintaining a gloomy or hopeless outlook, believing that everything is "unfair", or feeling helpless or that they disappoint others.

However, pediatric patients may lack the emotional and cognitive ability to correctly identify and organize their emotional experiences, and depressive disorders may express themselves with an irritable mood [30]. Irritability can manifest as feeling "annoyed," “grouchy,” or "bothered" by everything and everyone. Rather than expressing sadness, patients with depressive disorders may be negative and argumentative, and pick fights as a means to convey their emotional distress. Patients may be unable to tolerate frustration and respond to minor provocations with angry outbursts.

Depressed mood appears to be more common than irritable mood in pediatric depression. A prospective study of children and adolescents with depressive disorders (n >1400) found that depressed mood occurred in approximately 58 percent, depressed mood plus irritable mood in 36 percent, and irritable mood in only 6 percent [31]. Although irritability is a nonspecific symptom found in many child psychiatric disorders, longitudinal follow-up studies indicate that irritability is associated with adult depressive disorders [32].

Mood reactivity (the capacity to be cheered up in response to positive events) occurs in depression with atypical features (eg, hyperphagia or hypersomnia), which may be more common in children. By contrast, depression with melancholic features may be more common in adolescents. (See 'Depressive episode specifiers' below.)

Mood reactivity can cause adolescents to seek activities and experiences to temporarily lift their moods. Examples of these activities include affiliation with peers, thrill-seeking, promiscuity, and drug use [33]. The use of peer affiliation to alleviate depression is marked by an intense urgency and drive, in contrast to the normal adolescent need for peer affiliation. Depressed adolescents, particularly girls, may often co-ruminate with another depressed peer, thereby reinforcing and increasing depressive severity [34].

Diminished interest or pleasure – Loss of interest or pleasure (anhedonia) in formerly pleasurable activities is also a cardinal symptom of unipolar major depression. Patients experience events, hobbies, interests, and people as less interesting or fun than previously. Anhedonia may be expressed by describing experiences as "boring," "stupid," or "uninteresting." They may withdraw from or lose interest in friends. If they are sexually active, they may have decreased libido or interest in sex [35].

Change in appetite or weight – Appetite and weight may decrease or increase in depression. Decreased appetite may manifest with failure to gain weight as expected, rather than weight loss. Alternatively, some patients with depressive disorders crave and eat more specific foods (eg, junk food and carbohydrates) and gain more weight than expected during their adolescent growth spurt.

Preoccupation with weight and body image are signs of anorexia nervosa. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis", section on 'Anorexia nervosa'.)

Sleep disturbance – Sleep disturbance manifests as insomnia, hypersomnia, or significant shifts of sleep pattern over the diurnal cycle:

Initial insomnia (difficulty getting to sleep)

Middle insomnia (waking in the middle of the night, with difficulty returning to sleep)

Terminal insomnia (waking too early and being unable to return to sleep)

Hypersomnia (extended nighttime sleep or daytime sleeping)

Circadian reversal (daytime sleeping and nighttime arousal)

Many depressed patients describe their sleep as nonrestorative and report difficulty getting out of bed in the morning.

Psychomotor agitation or retardation – Psychomotor agitation refers to handwringing; the inability to sit still; pacing; or pulling or rubbing clothes, the skin, or other objects. Alternatively, depressed patients with psychomotor retardation talk or move more slowly than is typical for them; in addition, speech volume or inflection may be decreased, and the amount of speech may be diminished. Psychomotor agitation or retardation is regarded as a depressive symptom only if it is noticeable to others, in contrast to subjective feelings of restlessness or feeling slowed down. Retardation and agitation may alternate within a single depressive episode.

Fatigue or loss of energy – Lack of energy (anergia) manifests with feeling tired, exhausted, listless, and unmotivated. Patients may feel the need to rest during the day, experience heaviness in their limbs, or feel like it is hard to initiate activities. Parent-adolescent conflicts can result if parents attribute lack of energy and motivation to laziness, an oppositional attitude, or avoidance of responsibilities. Alternatively, parents may be concerned that the patient has a general medical illness and seek a medical explanation for the anergia.

Feelings of worthlessness or guilt – The self-perceptions of depressed children and adolescents may be marked by feelings of inadequacy, inferiority, failure, worthlessness, and guilt. Evaluation of this symptom is challenging because many youth do not directly acknowledge such negative self-perceptions. In addition, guilt about struggling with depression and its associated functional impairment is not considered a symptom of depression unless the guilt is of delusional proportions.

Feelings of worthlessness or guilt may manifest as:

Excessively self-critical assessment of accomplishments

Difficulty identifying positive self-attributes

Strong dissatisfaction with several aspects of themselves

Compulsive lying about success or skills to bolster self-esteem

Envy or preoccupation with the success of others, especially in comparison with self-evaluation

Marked self-reproach or guilt for events that are not their fault

Belief that they deserve to be punished for things that are not their fault

Reluctance to try to do things because patients fear they will fail, and decide “what’s the use?”

Impaired concentration and decision making – Depressed youth can have problems with attention, concentration, and memory that were not present to the same degree before the depressive episode. Thinking and processing of information may be slowed. In addition, patients are indecisive, which manifests as procrastination, helplessness, or paralysis in taking action. It can take longer to complete homework and class work than before the depressive episode; school performance may thus decline. Information from the school is helpful to evaluate this symptom.

Recurring thoughts of death or suicide – Depressed patients can experience recurrent thoughts of death (not just fear of death) or suicide, or attempt suicide. Morbid thoughts are common in depressed teens and can manifest as preoccupation with music and literature that has morbid themes, or as passive suicidal ideation (eg, thoughts that life is not worth living or that others would be better off if the patient was dead). In addition, there may be active suicidal ideation of wanting to die or killing oneself, suicide plans, suicide pacts, and suicide attempts. Thoughts that contribute to suicidality include pervasive hopelessness (eg, negative expectations for the future) and a view of suicide as the only option to escape emotional pain. Risk factors, assessment, and management of suicidal behavior in children and adolescents is discussed separately. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors" and "Suicidal ideation and behavior in children and adolescents: Prevention and treatment".)

Psychosis Major depression may include delusions and hallucinations (eg, command auditory hallucinations telling patients to commit suicide). (See "Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis", section on 'Psychotic features'.)

Functional impairment — Functional impairment in depressed children and adolescents includes disturbances in school functioning, relationships with parents and peers, and daily activities and responsibilities [4,29]. In addition, depressed adolescents are at increased risk for engaging in health risk behaviors such as promiscuity [36,37]. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

The academic and social sequelae of depression during childhood and adolescence reinforce depression once an episode begins, and increase the risk for future depressive episodes [30]. Examples of sequelae that perpetuate or trigger new episodes of depression include [38,39]:

Academic failure and school avoidance

Interpersonal dysfunction with family, peers, and teachers

Social withdrawal

Negative attributions about the perceptions or intent of others

Seeking reassurance excessively

These sequelae are most notable during adolescence, when most teens strive to define themselves and establish a social role outside the family.

Pediatric depression is associated with adverse psychosocial outcomes in adulthood. As an example, a systematic review identified 25 prospective studies that enrolled adolescents (total n >21,000) with and without depression; functioning during adulthood was assessed during an average follow-up of nine years [40]. Meta-analyses found that compared with controls, depressed adolescents were more likely to not complete secondary school (odds ratio 1.8, 95% CI 1.3-2.4) and to be unemployed (odds ratio 1.7, 95% CI 1.3-2.1).

Comorbidity

Psychiatric — Psychiatric comorbidity is the rule rather than the exception for pediatric depression. A nationally representative survey of adolescents in the United States found that among the individuals with major depression, at least one comorbid psychiatric disorder was present in more than 60 percent [6]; this is consistent with a review that found comorbidity was present in 40 to 90 percent of depressed children and adolescents, and two or more comorbid diagnoses were found in up to 50 percent [41]. The most common comorbidities include [3,6]:

Anxiety disorders (see "Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course")

Attention deficit hyperactivity disorder (ADHD) (see "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis")

Disruptive behavior disorders (eg, oppositional defiant disorder and conduct disorder)

Substance use disorders

Depressed children may be more likely to suffer comorbid ADHD and separation anxiety disorder, whereas depressed adolescents appear to be more vulnerable to substance use disorders.

Patients struggling with depression are also at increased risk for eating disorders, learning disorders, and somatic symptom disorders, and have often suffered physical or sexual abuse, or other traumas. In addition, depressed patients are more likely to manifest health problems or somatic concerns [42,43].

Depression in children and adolescents usually emerges after the comorbid disorder [41]. Anxiety disorder and oppositional defiant disorder are particularly strong predictors of eventual depression. Although substance abuse is more likely to precede depression than follow it, substance abuse can also emerge as a complication of depression.

Comorbidity adversely affects outcomes in depressed patients, and is associated with a longer duration of illness, poorer response to treatment, and increased recurrence of depressive episodes [44,45]. In addition, comorbidity is associated with social problems, academic difficulties, and global role impairment, and accounts for some of the longer term sequelae (eg, depression and suicidality during adulthood) associated with juvenile depression [46-48].

Comorbid cannabis use disorder is common among depressed youth and appears to be associated with increased self-harm and mortality. A retrospective study of an administrative claims database identified youths with a mean age of 17 years who had mood disorders and were followed for up to one year (n >200,000) [49]. The primary diagnosis was depressive disorder in nearly 75 percent and bipolar disorder or another mood disorder in the remaining youths; cannabis use disorder was present in 10 percent of the entire sample. After controlling for potential confounding demographic, clinical, and treatment factors, the analyses found an increased risk for each of the following outcomes in patients with comorbid cannabis use disorder:

Nonfatal self-harm – Hazard ratio 3.3 (95% CI 2.6-4.2)

All-cause death – Hazard ratio 1.6 (95% CI 1.1-2.2)

Death by unintentional overdose – Hazard ratio 2.4 (95% CI 1.4-4.2)

Death by homicide – Hazard ratio 3.2 (95% CI 1.2-8.6)

Among adolescents who are initially and correctly diagnosed with unipolar major depression, comorbid subsyndromal manic symptoms and disruptive behavior disorders are associated with an increased risk of eventually suffering a manic or hypomanic episode [50,51].

General medical — Major depression in adolescence may be associated with premature atherosclerosis and cardiovascular disease. The mechanism appears to involve multiple systemic processes, including inflammation, oxidative stress, and autonomic dysfunction [52]. Several traditional cardiovascular risk factors (eg, diabetes mellitus, obesity, sedentary lifestyle, and tobacco smoking) are more prevalent among adolescents with major depression compared with the general pediatric population. Based upon available data, the American Heart Association proposed in a 2015 statement that major depression be positioned alongside other pediatric diseases (chronic inflammatory disease, infection with the human immunodeficiency virus, Kawasaki disease, and nephrotic syndrome) that are considered moderate risk conditions for early cardiovascular disease [52]. Additional information about diseases that are associated with pediatric atherosclerosis is discussed separately, as is the management of youth at risk for atherosclerosis (algorithm 1). (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood" and "Overview of the management of the child or adolescent at risk for premature atherosclerotic cardiovascular disease (ASCVD)".)

Course of illness

Children — A review found that in children with major depression who are seen in clinical settings, the average duration of depressive episodes ranged from 8 to 13 months [53]. Among those who recovered from the episode, relapse or recurrence occurred in 30 to 70 percent. Children with major depression, particularly those with a family history of mood disorder, are more likely to suffer adolescent depression, compared with children who are not depressed.

Adolescents — In adolescents with major depression who were seen in clinical settings, studies have found that the average duration of depressive episodes ranged from four to nine months, and that 90 percent of the episodes remitted within two years [44,53]. Among those who recovered from the episode, at least one recurrence was observed in 20 to 70 percent. Adolescents with major depression are more likely to suffer depression in adulthood, compared with adolescents who are not depressed.

Recurrence — Risk factors for recurrence of pediatric major depression include [41,54]:

History of prior depressive episodes

Presence of residual depressive symptoms

Presence of comorbid disorders

Environmental stressors

Limited social supports

Family history of recurrent unipolar major depression or other psychopathology

SCREENING — Screening for depression is discussed separately. (See "Screening tests in children and adolescents", section on 'Depression and suicide risk screening'.)

ASSESSMENT — The initial clinical evaluation of children and adolescents with a possible diagnosis of a depressive disorder includes a psychiatric and general medical history, mental status and physical examination, and focused laboratory tests (eg, thyroid stimulating hormone, complete blood count, chemistries, and urine toxicology to screen for substances of abuse) [55-57].

Evaluation of depression can be difficult because of nonspecific symptoms, comorbidities, and the differential diagnosis. Depression in children and adolescents may be misunderstood by youths, parents, and professionals alike. The following points provide guidelines to consider when evaluating patients for depression:

Diagnosis should be based upon a formal clinical interview with the child or adolescent that is supplemented by information from parents and teachers [3,41,58]. Standardized instruments are available as screening tools and to monitor outcomes, but they should not be used as the basis for diagnosis. Examples include the self-report Patient Health Questionnaire – Nine Item (PHQ-9): Modified for Teens (table 1), Mood and Feelings Questionnaire [59,60], Patient Reported Outcome Measurement Information System [61], Beck Depression Inventory [62], the Child Depression Inventory [63], or the Reynolds Adolescent Depression Scale [64].

The Mood and Feelings Questionnaire has a separate form that is completed by the child or adolescent and the parent; the questionnaire is validated for both children and adolescents and is in the public domain. The Patient Reported Outcome Measurement Information System performed better than the Beck Depression Inventory over the full range of depressive symptoms. The Child Depression Inventory is designed for children 7 to 17 years of age and is available for purchase through Multi-Health Systems, Inc. The Reynolds Adolescent Depression Scale is designed for teens in grades 7 through 12 and is published by Psychological Assessment Resources, Inc.

Questions should be phrased in a manner that is normalizing and not stigmatizing (eg, "Everyone I know gets sad sometimes; what kinds of things usually make you sad? Would you say you're usually happy, sad, or in-between?"). Particularly for guarded children and adolescents, more direct questions with empathic responses for their unique experience usually are best tolerated once the youth trusts that it is okay to discuss such topics. Likert scales are helpful for patients who have trouble describing their experiences (eg, "On a scale of 1 to 10, how annoyed have you been lately?").

The evaluation should be sensitive to the patient’s age as well as cultural, ethnic, and religious background.

Clinicians must assess children and adolescents for suicidal and homicidal ideation and behavior, including risk and protective factors that may influence suicide risk, as well as psychotic symptoms [41].

The initial assessment should look for comorbid conditions [3], and rule out other psychiatric and general medical disorders that may cause depressive syndromes (eg, substance use disorders and hypothyroidism). If a patient has a pre-existing comorbid condition, an overlapping symptom (eg, poor concentration in a child with pre-existing ADHD) should only be counted towards the diagnosis of depression if the symptom has worsened with the advent of other depressive symptoms.

Pediatric depression should be evaluated in the context of precipitants, stressors, and academic, social, and family functioning [41]. Examples include family and contextual factors that may precipitate or prolong a depressive episode, such as parental depression, parent-child discord, history of abuse or assault, witnessing violence or peer victimization, recent loss, same sex attraction, and gender dysphoria. These factors will guide appropriate intervention, including a treatment plan that targets circumstances that maintain depression and put the adolescent at risk for future episodes.

Children and adolescents in primary care who present with depressive syndromes that are not readily diagnosable can benefit from referral to psychiatrists or other mental health specialists for further assessment.

Patients and/or parents may resist the diagnosis of depression and continue to seek a "medical" explanation for presenting symptoms. In these cases, it is often beneficial to join the child or adolescent or family members in their understanding of the presenting concern and extend their view with psychoeducation (eg, "You've been experiencing considerable fatigue that has been immobilizing; it is very common to feel discouraged, annoyed, or even depressed when faced with this kind of stress day in and day out.")

Although children, adolescents, and their families may initially resist accepting a diagnosis of a depressive disorder, they often come to view the diagnosis of depression as reassuring. The explanation for the symptoms can provide a sense of control and is a significant step toward symptom relief.

DIAGNOSING DEPRESSIVE DISORDERS — In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the depressive disorders that can be diagnosed include [29]:

Unipolar major depression (major depressive disorder)

Persistent depressive disorder (dysthymia)

Minor depression

Disruptive mood dysregulation disorder

Premenstrual dysphoric disorder

Substance/medication induced depressive disorder

Depressive disorder due to another medical condition

Each of the disorders is characterized by dysphoria (sad or irritable mood) [29].

Unipolar major depression — Unipolar major depression (major depressive disorder) is characterized by a history of one or more major depressive episodes (table 2) and no history of mania (table 3) or hypomania (table 4) [29]. To meet DSM-5 criteria for a major depressive episode, the child or adolescent must display at least five of the following depressive symptoms for at least two weeks; at least one of the symptoms is either dysphoria or anhedonia:

Depressed or irritable mood (dysphoria)

Diminished interest or pleasure in almost all activities (anhedonia)

Change in appetite or weight

Insomnia or hypersomnia

Psychomotor agitation or retardation

Fatigue or loss of energy

Feelings of worthlessness or guilt

Impaired thinking or concentration, indecisiveness

Suicidal ideation or behavior

The symptoms must cause significant distress or psychosocial impairment, and are not the direct result of a substance or general medical condition. (See 'Substance/medication induced depressive disorder' below and 'Depressive disorder due to another medical condition' below.)

Bereavement does not exclude the diagnosis of a major depressive episode. (See "Bereavement and grief in adults: Clinical features", section on 'Unipolar major depression'.)

A prior history of mania or hypomania indicates the diagnosis of bipolar depression. (See 'Bipolar depression' below.)

Depressive episode specifiers — DSM-5 utilizes the following terms to increase the diagnostic specificity of major depressive episodes [29]. The specifier is added when recording the diagnosis; as an example, “unipolar major depression with psychotic features.”

Anxious distress – Anxious distress is characterized by the presence of two or more of the following symptoms during most days of the depressive episode:

Tension

Restless

Impaired concentration due to worry

Fear that something awful may happen

Fear of losing self-control

Atypical features – Atypical features are characterized by at least three of the following symptoms; at least one of the symptoms is mood reactivity to pleasurable stimuli:

Reactive to pleasurable stimuli (ie, feels better in response to positive events)

Increased appetite or weight gain

Hypersomnia (eg, sleeping at least 10 hours per day, or at least 2 hours more than usual when not depressed)

Heavy or leaden feelings in limbs

Longstanding pattern of interpersonal rejection sensitivity (ie, feeling deep anxiety, humiliation, or anger at the slightest rebuff from others), which is not limited to mood episodes and which causes social or occupational conflicts

Catatonia – Catatonic features are characterized by prominent psychomotor disturbances (see "Catatonia in adults: Epidemiology, clinical features, assessment, and diagnosis")

Melancholic features – Melancholic features are characterized by at least four of the following symptoms; at least one of the symptoms is either loss of pleasure or lack of reactivity to pleasurable stimuli:

Loss of pleasure in most activities

Unreactive to usually pleasurable stimuli (ie, does not feel better in response to positive events)

Depressed mood marked by despondency, despair, or remorse

Early morning awakening (eg, two hours before the usual hour of awakening)

Psychomotor retardation or agitation

Anorexia or weight loss

Excessive guilt

Mixed features – Unipolar major depression and persistent depressive disorder (dysthymia) can be accompanied by subthreshold (not meeting full criteria) symptoms of hypomania or mania. Depressive episodes with mixed features are characterized by full criteria for the depressive episode and at least three of the following symptoms during most days of the episode:

Elevated or expansive mood

Inflated self-esteem or grandiosity

More talkative than usual or pressured speech

Flight of ideas (abrupt changes from one topic to another that are based upon understandable associations) or racing thoughts

Increased energy or goal-directed activity

Excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, buying sprees or sexual indiscretions)

Decreased need for sleep

If full criteria for hypomania (table 4) or mania (table 3) are met, the diagnosis is bipolar disorder, hypomania, or bipolar disorder, mania with mixed features, rather than unipolar depression with mixed features. (See 'Bipolar depression' below.)

Peripartum onset – Peripartum onset refers to onset of mood episodes during pregnancy or within four weeks of childbirth. (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis" and "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

Psychotic features – Psychotic features include delusions (false, fixed beliefs) and hallucinations (false sensory perceptions). (See "Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis", section on 'Psychotic features'.)

Seasonal pattern – Seasonal pattern refers to a regular temporal relationship between the onset of major depression and a particular time of year, (eg, fall or winter). Remission also occurs at a specific time of year (eg, spring). In the last two years, two depressive episodes have occurred that demonstrate the temporal relationship and no nonseasonal episodes have occurred. In addition, the lifetime number of seasonal depressions substantially outnumbers the nonseasonal episodes. Seasonal pattern is not used as a specifier if depressive episodes occur in response to a seasonally related psychosocial stressor (eg, stress at school), or if episodes occur at other times of the year as well as seasonally.

Additional information about the seasonal pattern of major depression is discussed separately. (See "Seasonal affective disorder: Epidemiology, clinical features, assessment, and diagnosis".)

Persistent depressive disorder (dysthymia) — Persistent depressive disorder (dysthymia) is marked by depressed mood for at least one year (table 5) [29]. Depression is present for most of the day, for more days than not, and is accompanied by two or more of the following symptoms:

Decreased or increased appetite

Insomnia or hypersomnia

Low energy

Poor self esteem

Poor concentration

Hopelessness

Thus, symptoms are not as numerous as in major depression. Symptom-free periods during the course of persistent depressive disorder can occur, but may not exceed two months during the one year timeframe. A major depressive episode may be present during the one year (or longer) period of persistent depressive disorder.

The mood disturbance in persistent depressive disorder causes significant distress or psychosocial impairment.

Persistent depressive disorder is not diagnosed in patients with a prior history of mania (table 3), hypomania (table 4), or cyclothymic disorder, nor is it diagnosed if the mood disturbance is better explained by schizophrenia (table 6), schizoaffective disorder, or delusional disorder. (See "Pediatric bipolar disorder: Assessment and diagnosis", section on 'Bipolar disorders' and "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation", section on 'Mood disorders and suicidal ideation'.)

In addition, persistent depressive disorder is not diagnosed if the mood disturbance is due to the physiologic effects of a substance or medication, or a general medical disorder. (See 'Substance/medication induced depressive disorder' below and 'Depressive disorder due to another medical condition' below.)

Minor depression — The continuum of clinical depression increases in severity from symptoms to minor depression to major depression [5,65,66].

Diagnostic criteria for minor depression typically include two to four depressive symptoms (see 'Symptoms' above), at least one of which is dysphoria or anhedonia. In addition, the symptoms cause significant distress or psychosocial impairment. In DSM-5, minor depression is classified as ”other specified depressive disorder, depressive episode with insufficient symptoms” [29]. Additional information about the clinical features and diagnosis of minor depression is discussed separately. (See "Unipolar minor depression in adults: Epidemiology, clinical presentation, and diagnosis".)

A systematic review of 24 clinical or community studies found that the estimated lifetime prevalence of pediatric minor depression ranged from 5 to 12 percent, and that suicidal behavior occurred in approximately 10 percent of the individuals with minor depression [5]. In addition, many of the depressed youth had comorbid psychopathology (eg, anxiety disorders, conduct disorder, and oppositional defiant disorder), and functional impairment was generally comparable to that found in unipolar major depression. Compared with adolescents without minor depression, adolescents with minor depression were at increased risk for psychopathology as adults, including unipolar major depression, generalized anxiety disorder, and posttraumatic stress disorder. Hence, “minor” depression causes clinical impairment and should be taken seriously.

Disruptive mood dysregulation disorder — The diagnosis of disruptive mood dysregulation disorder requires each of the following criteria [29]:

Severe, recurrent verbal (eg, screaming) or behavioral (eg, physical aggression) angry outbursts that are grossly out of proportion to the provocation.

The outbursts are not appropriate for the patient’s developmental level.

The outbursts occur, on average, at least three times per week.

The outbursts occur in at least two settings from among home, school, or with peers.

Persistently irritable or angry mood most of the day, nearly every day, between outbursts.

Symptoms have occurred for at least 12 months. Symptom free periods can occur, but may not exceed three months during the one year timeframe.

Age at onset <10 years. The diagnosis cannot be given for the first time before age 6 years or after age 18 years.

The patient has never had a period lasting more than one day during which the full symptom criteria for mania or hypomania, except duration, have been met.

Symptoms do not occur solely during unipolar major depressive episodes, and are not better explained by other mental disorders (eg, autism).

The symptoms are not attributable to the physiologic effects of a substance or medication, or to another medical disorder. (See 'Substance/medication induced depressive disorder' below and 'Depressive disorder due to another medical condition' below.)

Disruptive mood dysregulation disorder may be comorbid with unipolar major depression, attention deficit hyperactivity disorder, conduct disorder, and substance use disorders [29]. However, the diagnosis of disruptive mood dysregulation disorder, according to DSM-5, cannot be given simultaneously with the diagnoses of bipolar disorder, intermittent explosive disorder, and oppositional defiant disorder.

Disruptive mood dysregulation and intermittent explosive disorder are both characterized by recurrent, severe, angry outbursts [29]. However, patients with disruptive mood dysregulation disorder are angry or irritable most of the day, nearly every day, in between the angry outbursts, whereas the diagnosis of intermittent explosive disorder does not require a mood disturbance between outbursts. In addition, angry outbursts in disruptive mood dysregulation disorder occur on average three times per week; in intermittent explosive disorder, verbal aggression occurs on average twice per week. Disruptive mood dysregulation disorder requires 12 months of active symptoms, in contrast to intermittent explosive disorder, which requires only 3 months of symptoms.

Premenstrual dysphoric disorder — Premenstrual dysphoric disorder is marked by emotional and behavioral symptoms, which occur repeatedly during the week before onset of menses and remit with onset of menses or a few days thereafter, and which interfere with some aspect of the adolescent’s life. (See "Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder".)

Substance/medication induced depressive disorder — Substance/medication induced depressive disorder consists of a mood disturbance that is characterized by a persistently depressed or irritable mood, or diminished interest or pleasure in most activities [29]. The mood disturbance develops during or soon after using substances (eg, alcohol, cocaine, opiates, and amphetamines) or medications (eg, interferon, stimulants, or systemic corticosteroids) that are capable of producing the symptoms. In addition, the disturbance causes significant distress or impairs psychosocial functioning.

Substance/medication induced depressive disorder is not diagnosed in the following situations:

The mood disturbance precedes onset of substance intoxication or withdrawal, or exposure to medications

The disturbance persists for a long period of time (eg, one month) after cessation of acute intoxication or withdrawal

There is a prior history of recurrent depressive episodes

The disturbance occurs solely during an episode of delirium (see "Diagnosis of delirium and confusional states")

Depressive disorder due to another medical condition — Depressive disorder due to a general medical condition consists of a mood disturbance that is characterized by a persistently depressed or irritable mood, or diminished interest or pleasure in most activities [29]. Findings from the history, physical examination, or laboratory tests indicate that the disturbance is caused by another medical condition (eg, adrenal insufficiency, hypercortisolism, hypothyroidism, mononucleosis, multiple sclerosis, traumatic brain injury, systemic lupus erythematosus, or vitamin B12 insufficiency). In addition, the disturbance results in significant distress or impairs psychosocial functioning. Onset of the mood disturbance generally occurs during the first month of the onset of the other medical condition.

Depressive disorder due to another medical condition is not diagnosed if the mood disturbance precedes onset of the medical condition or occurs solely during an episode of delirium. (See "Diagnosis of delirium and confusional states".)

Depression can be diagnosed in the context of chronic illness if there is not a direct causal link between the illness and depression. As an example, the risk for depression is higher in patients with epilepsy, migraine, inflammatory bowel disease, and asthma, but the diagnosis of depression can be made in these conditions, taking care to differentiate somatic symptoms of depression from those of chronic illness (eg, anorexia, insomnia, fatigue, and psychomotor retardation). (See "Unipolar depression in adults: Assessment and diagnosis".)

Other specified depressive disorder — Other specified depressive disorder applies to patients with depressive symptoms that cause significant distress or impair psychosocial functioning but do not meet the full criteria for a specific depressive disorder [29]. Clinicians record the diagnosis other specified depressive disorder, followed by the reason that the presentation does not meet full criteria for a specific depressive disorder. As an example, “other specified depressive disorder, recurrent brief depression.” The syndrome of recurrent brief depression refers to patients who present with recurrent periods lasting for less than two weeks that are marked by depressed or irritable mood and at least four other depressive symptoms.

Unspecified depressive disorder — Unspecified depressive disorder applies to patients with depressive symptoms that cause significant distress or impair psychosocial functioning but do not meet the full criteria for a specific depressive disorder [29]. This diagnosis is used when clinicians decide to not specify the reason that the presenting syndrome does not meet the full criteria for a specific depressive disorder, and can include situations in which there is insufficient information to make a more specific diagnosis (eg, in the emergency department).

DIFFERENTIAL DIAGNOSIS — The differential diagnosis for pediatric unipolar depression includes adjustment disorder with depressed mood, bipolar depression, and sadness.

Adjustment disorder with depressed mood — Adjustment disorder with depressed mood is marked by depression that occurs in response to an identifiable psychosocial stressor (eg, parental divorce, academic failure, or peer problems) [29]. The stressor may be a single event or there may be multiple stressors, and a stressor may be recurrent or continuous. Adjustment disorder with depressed mood is not classified as a depressive disorder. Rather, adjustment disorder describes patients suffering significant symptoms that do not meet criteria for a more specific psychiatric disorder.

The criteria for adjustment disorder with depressed mood are as follows [29]:

Low mood, tearfulness, or hopelessness that occurs in response to an identifiable stressor within three months of onset of the stressor

Symptoms are clinically significant as evidenced by at least one of the following:

Significant distress that exceeds what would be expected given the nature of the stressor

Impaired social or occupational functioning

The syndrome does not meet criteria for another psychiatric disorder (eg, major depression)

The syndrome does not represent an exacerbation of a preexisting psychiatric disorder

The syndrome does not represent bereavement

After the stressor and its consequences have ended, the syndrome resolves within six months

Major depression and persistent depressive disorder (dysthymia) often occur in the context of psychosocial stressors, and the diagnosis of adjustment disorder with depressed mood is superseded by a depressive disorder. Clinicians distinguish a depressive disorder from an adjustment disorder not by noting whether a stressor is present, but by determining whether the patient’s symptoms are sufficient in number, severity, and duration to meet diagnostic criteria for a depressive disorder.

Adjustment disorder with depressed mood can persist beyond six months if the stressor is chronic (eg, ongoing parental conflict).

Bipolar depression — Episodes of major depression occur in both unipolar major depression (major depressive disorder) and bipolar disorder; however, patients with bipolar disorder have a prior history of manic/hypomanic episodes, whereas patients with unipolar major depression do not [29]. Nevertheless, bipolar disorder is frequently misidentified as unipolar major depression [67-72] because the mood episode at onset of bipolar disorder is often a depressive episode [73-75], multiple episodes of major depression may occur prior to the first lifetime episode of mania or hypomania [76], and depressive symptoms occur more frequently than mood elevated symptoms [77,78]. In addition, clinicians may not recognize mania/hypomania due to the presence of comorbid disorders [79,80].

Additional information about differentiating unipolar depression from bipolar depression is discussed separately. (See "Pediatric bipolar disorder: Assessment and diagnosis", section on 'Unipolar major depression' and "Bipolar disorder in adults: Assessment and diagnosis", section on 'Unipolar major depression'.)

Sadness — Periods of sadness and irritability (dysphoria) in the absence of other symptoms do not warrant a diagnosis of a depressive disorder. As an example, the diagnosis of unipolar major depression requires not only that the dysphoria occurs for most of the day for nearly every day for at least two weeks, but that the dysphoria is accompanied by at least four other depressive symptoms (see 'Symptoms' above) as well as significant distress or psychosocial impairment (table 2). Sadness and irritability are a normal, adaptive part of the human condition, particularly in response to loss, disappointment, or perceived failure.

Patients with other conditions, such as anxiety disorders, attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders, substance use disorders, and eating disorders can experience sadness and demoralization. The dysphoria of anxiety disorders is primarily limited to that experienced when an anxiogenic situation cannot be avoided. Youth with ADHD may be demoralized by rejection from parents, peers and teachers, but this should remit if the ADHD is properly treated. Substance abuse can induce depression, and depression increases the risk for substance abuse. Patients with eating disorders may be dysphoric or listless due to caloric restriction, or conversely, due to being forced to eat and achieve a normal weight.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Depression in children and teens (The Basics)")

Beyond the Basics topic (see "Patient education: Depression in children and adolescents (Beyond the Basics)")

SUMMARY

Epidemiology

Prevalence – The estimated lifetime prevalence of depression in children age 6 to 11 years is 2 percent, and in adolescents age 12 to 17 years is 7 percent. (See 'Prevalence' above.)

Sex ratio – The prevalence of depression in prepubertal children appears to be greater in boys than girls. In adolescents, depression occurs more often in girls than boys, in a ratio of approximately 2:1. (See 'Sex ratio' above.)

Clinical features

Symptoms – Symptoms of depression include dysphoria, anhedonia, appetite or weight change, sleep disturbance, psychomotor agitation or retardation, anergia, thoughts of worthlessness or inappropriate guilt, impaired cognition, and recurrent thoughts of death or suicide or suicide attempt. (See 'Symptoms' above.)

Functional impairment – Functional impairment in pediatric depression includes disturbances in school functioning, relationships with parents and peers, and daily activities and responsibilities. (See 'Functional impairment' above.)

Comorbidity – Pediatric depression is often comorbid with substance use disorders, anxiety disorders, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder, and predisposes youth to early cardiovascular disease. (See 'Comorbidity' above.)

Assessment – The initial clinical evaluation of patients with a possible diagnosis of a depressive disorder includes a psychiatric and general medical history, mental status and physical examination, and focused laboratory tests. The history should be supplemented by information from parents and teachers, and should include assessment of suicidal and homicidal ideation and behavior, comorbid disorders, and psychosocial functioning. (See 'Assessment' above.)

Diagnosis

Unipolar major depression – The diagnostic criteria for unipolar major depression are described in the table (table 2). (See 'Unipolar major depression' above.)

Persistent depressive disorder (dysthymia) – The diagnostic criteria for persistent depressive disorder (dysthymia) are described in the table (table 5). (See 'Persistent depressive disorder (dysthymia)' above.)

Minor depression – Diagnostic criteria for minor depression include two to four depressive symptoms, at least one of which is dysphoria or anhedonia. In addition, the symptoms cause significant distress or psychosocial impairment. (See 'Symptoms' above and 'Minor depression' above.)

Differential diagnosis – The differential diagnosis for pediatric depression includes adjustment disorder with depressed mood, bipolar major depression, and sadness. (See 'Differential diagnosis' above.)

  1. Saluja G, Iachan R, Scheidt PC, et al. Prevalence of and risk factors for depressive symptoms among young adolescents. Arch Pediatr Adolesc Med 2004; 158:760.
  2. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health surveillance among children--United States, 2005-2011. MMWR Suppl 2013; 62:1.
  3. Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007; 120:e1299.
  4. Asarnow JR, Jaycox LH, Duan N, et al. Depression and role impairment among adolescents in primary care clinics. J Adolesc Health 2005; 37:477.
  5. Wesselhoeft R, Sørensen MJ, Heiervang ER, Bilenberg N. Subthreshold depression in children and adolescents - a systematic review. J Affect Disord 2013; 151:7.
  6. Avenevoli S, Swendsen J, He JP, et al. Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry 2015; 54:37.
  7. Seedat S, Scott KM, Angermeyer MC, et al. Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry 2009; 66:785.
  8. Maughan B, Collishaw S, Stringaris A. Depression in childhood and adolescence. J Can Acad Child Adolesc Psychiatry 2013; 22:35.
  9. Douglas J, Scott J. A systematic review of gender-specific rates of unipolar and bipolar disorders in community studies of pre-pubertal children. Bipolar Disord 2014; 16:5.
  10. Fleming JE, Offord DR. Epidemiology of childhood depressive disorders: a critical review. J Am Acad Child Adolesc Psychiatry 1990; 29:571.
  11. Kutcher S, Marton P. Affective disorders in first-degree relatives of adolescent onset bipolars, unipolars, and normal controls. J Am Acad Child Adolesc Psychiatry 1991; 30:75.
  12. Warner V, Weissman MM, Mufson L, Wickramaratne PJ. Grandparents, parents, and grandchildren at high risk for depression: a three-generation study. J Am Acad Child Adolesc Psychiatry 1999; 38:289.
  13. Lewinsohn PM, Roberts RE, Seeley JR, et al. Adolescent psychopathology: II. Psychosocial risk factors for depression. J Abnorm Psychol 1994; 103:302.
  14. Rutter, M. Children of sick parents: An environment and psychiatric study, Oxford University Press, 1966.
  15. Reinherz HZ, Giaconia RM, Pakiz B, et al. Psychosocial risks for major depression in late adolescence: a longitudinal community study. J Am Acad Child Adolesc Psychiatry 1993; 32:1155.
  16. Adrian C, Hammen C. Stress exposure and stress generation in children of depressed mothers. J Consult Clin Psychol 1993; 61:354.
  17. Garber, J, Hilsman, R. Cognition, stress and depression in children and adolescents. Child Adolesc Psychiatr Clin N Am 1992; 1:129.
  18. Hilsman R, Garber J. A test of the cognitive diathesis-stress model of depression in children: academic stressors, attributional style, perceived competence, and control. J Pers Soc Psychol 1995; 69:370.
  19. Burke P, Elliott M. Depression in pediatric chronic illness. A diathesis-stress model. Psychosomatics 1999; 40:5.
  20. Kendler KS. Genetic epidemiology in psychiatry. Taking both genes and environment seriously. Arch Gen Psychiatry 1995; 52:895.
  21. Williamson DE, Birmaher B, Frank E, et al. Nature of life events and difficulties in depressed adolescents. J Am Acad Child Adolesc Psychiatry 1998; 37:1049.
  22. Stringaris A, Lewis G, Maughan B. Developmental pathways from childhood conduct problems to early adult depression: findings from the ALSPAC cohort. Br J Psychiatry 2014; 205:17.
  23. Tsai MC, Tsai KJ, Wang HK, et al. Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study. J Pediatr 2014; 164:136.
  24. Chrisman SP, Richardson LP. Prevalence of diagnosed depression in adolescents with history of concussion. J Adolesc Health 2014; 54:582.
  25. Luby JL, Gaffrey MS, Tillman R, et al. Trajectories of preschool disorders to full DSM depression at school age and early adolescence: continuity of preschool depression. Am J Psychiatry 2014; 171:768.
  26. Pearson RM, Evans J, Kounali D, et al. Maternal depression during pregnancy and the postnatal period: risks and possible mechanisms for offspring depression at age 18 years. JAMA Psychiatry 2013; 70:1312.
  27. Bowes L, Joinson C, Wolke D, Lewis G. Peer victimisation during adolescence and its impact on depression in early adulthood: prospective cohort study in the United Kingdom. BMJ 2015; 350:h2469.
  28. Hamm MP, Newton AS, Chisholm A, et al. Prevalence and Effect of Cyberbullying on Children and Young People: A Scoping Review of Social Media Studies. JAMA Pediatr 2015; 169:770.
  29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, 2013.
  30. Cicchetti D, Toth SL. The development of depression in children and adolescents. Am Psychol 1998; 53:221.
  31. Stringaris A, Maughan B, Copeland WS, et al. Irritable mood as a symptom of depression in youth: prevalence, developmental, and clinical correlates in the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry 2013; 52:831.
  32. Stringaris A, Cohen P, Pine DS, Leibenluft E. Adult outcomes of youth irritability: a 20-year prospective community-based study. Am J Psychiatry 2009; 166:1048.
  33. Lehrer JA, Shrier LA, Gortmaker S, Buka S. Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students. Pediatrics 2006; 118:189.
  34. Hankin BL. Future directions in vulnerability to depression among youth: integrating risk factors and processes across multiple levels of analysis. J Clin Child Adolesc Psychol 2012; 41:695.
  35. Deumic Shultz E, Mills JA, Ellingrod VL, et al. Sexual Functioning in Adolescents With Major Depressive Disorder: A Prospective Study. J Clin Psychiatry 2021; 82.
  36. Deykin EY, Buka SL, Zeena TH. Depressive illness among chemically dependent adolescents. Am J Psychiatry 1992; 149:1341.
  37. Brown RA, Lewinsohn PM, Seeley JR, Wagner EF. Cigarette smoking, major depression, and other psychiatric disorders among adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35:1602.
  38. Joiner T, Coyne JC. The Interactional Nature of Depression, American Psychological Association, 1999.
  39. Beasley PJ, Beardslee WR. Depression in the adolescent patient. Adolesc Med 1998; 9:351.
  40. Clayborne ZM, Varin M, Colman I. Systematic Review and Meta-Analysis: Adolescent Depression and Long-Term Psychosocial Outcomes. J Am Acad Child Adolesc Psychiatry 2019; 58:72.
  41. Birmaher B, Brent D, AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007; 46:1503.
  42. Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches. J Am Acad Child Adolesc Psychiatry 1999; 38:852.
  43. Bernstein GA, Massie ED, Thuras PD, et al. Somatic symptoms in anxious-depressed school refusers. J Am Acad Child Adolesc Psychiatry 1997; 36:661.
  44. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996; 35:1427.
  45. Goodyer IM, Herbert J, Secher SM, Pearson J. Short-term outcome of major depression: I. Comorbidity and severity at presentation as predictors of persistent disorder. J Am Acad Child Adolesc Psychiatry 1997; 36:179.
  46. Lewinsohn PM, Rohde P, Seeley JR. Adolescent psychopathology: III. The clinical consequences of comorbidity. J Am Acad Child Adolesc Psychiatry 1995; 34:510.
  47. Fombonne E, Wostear G, Cooper V, et al. The Maudsley long-term follow-up of child and adolescent depression. 1. Psychiatric outcomes in adulthood. Br J Psychiatry 2001; 179:210.
  48. Fombonne E, Wostear G, Cooper V, et al. The Maudsley long-term follow-up of child and adolescent depression. 2. Suicidality, criminality and social dysfunction in adulthood. Br J Psychiatry 2001; 179:218.
  49. Fontanella CA, Steelesmith DL, Brock G, et al. Association of Cannabis Use With Self-harm and Mortality Risk Among Youths With Mood Disorders. JAMA Pediatr 2021; 175:377.
  50. Axelson D, Goldstein B, Goldstein T, et al. Diagnostic Precursors to Bipolar Disorder in Offspring of Parents With Bipolar Disorder: A Longitudinal Study. Am J Psychiatry 2015; 172:638.
  51. Faedda GL, Serra G, Marangoni C, et al. Clinical risk factors for bipolar disorders: a systematic review of prospective studies. J Affect Disord 2014; 168:314.
  52. Goldstein BI, Carnethon MR, Matthews KA, et al. Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2015; 132:965.
  53. Birmaher B, Arbelaez C, Brent D. Course and outcome of child and adolescent major depressive disorder. Child Adolesc Psychiatr Clin N Am 2002; 11:619.
  54. Birmaher B, Brent D. Depressive disorders. In: Psychopharmacology: Principles and Practice, Martin A, Scahill L, Charney DS, Leckman JF (Eds), Oxford University Press, 2003. p.466.
  55. Work Group on Psychiatric Evaluation, American Psychiatric Association Steering Committee on Practice Guidlines. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry 2006; 163:3.
  56. American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults, Second Edition, 2006. http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on July 18, 2011).
  57. Freudenreich O, Nejad SH, Francis A, Fricchione GL. Psychosis, mania, and catatonia. In: Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL (Ed), American Psychiatric Publishing, Washington, DC 2011. p.219.
  58. Brent DA, Birmaher B. Clinical practice. Adolescent depression. N Engl J Med 2002; 347:667.
  59. Thapar A, McGuffin P. Validity of the shortened Mood and Feelings Questionnaire in a community sample of children and adolescents: a preliminary research note. Psychiatry Res 1998; 81:259.
  60. Wood A, Kroll L, Moore A, Harrington R. Properties of the mood and feelings questionnaire in adolescent psychiatric outpatients: a research note. J Child Psychol Psychiatry 1995; 36:327.
  61. Olino TM, Yu L, McMakin DL, et al. Comparisons across depression assessment instruments in adolescence and young adulthood: an item response theory study using two linking methods. J Abnorm Child Psychol 2013; 41:1267.
  62. BECK AT, WARD CH, MENDELSON M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561.
  63. Kovacs M. Rating scales to assess depression in school-aged children. Acta Paedopsychiatr 1981; 46:305.
  64. Reynolds, WM. Adolescent Depression Scale, Psychological Assessment Resources, Inc, Odessa, FL 1987.
  65. Ayuso-Mateos JL, Nuevo R, Verdes E, et al. From depressive symptoms to depressive disorders: the relevance of thresholds. Br J Psychiatry 2010; 196:365.
  66. Lewinsohn PM, Klein DN, Durbin EC, et al. Family study of subthreshold depressive symptoms: risk factor for MDD? J Affect Disord 2003; 77:149.
  67. Bowden CL. A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord 2005; 84:117.
  68. Frye MA, Calabrese JR, Reed ML, et al. Use of health care services among persons who screen positive for bipolar disorder. Psychiatr Serv 2005; 56:1529.
  69. Smith DJ, Griffiths E, Kelly M, et al. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry 2011; 199:49.
  70. Stensland MD, Schultz JF, Frytak JR. Diagnosis of unipolar depression following initial identification of bipolar disorder: a common and costly misdiagnosis. J Clin Psychiatry 2008; 69:749.
  71. Hu C, Xiang YT, Ungvari GS, et al. Undiagnosed bipolar disorder in patients treated for major depression in China. J Affect Disord 2012; 140:181.
  72. Hantouche EG, Akiskal HS, Lancrenon S, et al. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord 1998; 50:163.
  73. Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry 1995; 34:454.
  74. Kupfer DJ, Frank E, Grochocinski VJ, et al. Demographic and clinical characteristics of individuals in a bipolar disorder case registry. J Clin Psychiatry 2002; 63:120.
  75. Cha B, Kim JH, Ha TH, et al. Polarity of the first episode and time to diagnosis of bipolar I disorder. Psychiatry Investig 2009; 6:96.
  76. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002; 159:1.
  77. Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002; 59:530.
  78. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003; 60:261.
  79. Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med 2005; 67:1.
  80. Matza LS, Rajagopalan KS, Thompson CL, de Lissovoy G. Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs. J Clin Psychiatry 2005; 66:1432.
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References

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