Adolescent Depression

Adolescence is a crucial stage in psychological, physiological, and social development, marked by intense changes in mood, relationships, and identity. During this period, sadness, irritability, and feelings of inadequacy can be part of normal growth, but in some cases, they indicate a true depressive disorder.

Many adolescents experience their first depressive episode during this phase of life, yet adolescent depression often goes underdiagnosed. Unlike adults, adolescents rarely verbalize their distress or consciously recognize that they are depressed, making early identification by family members and clinicians more challenging.

Adolescent depression is a multifactorial condition. In addition to genetic predisposition and neurobiological factors (alterations in serotonergic, noradrenergic, and dopaminergic circuits), stressful life events and environmental factors play a key role:

• dysfunctional family dynamics (conflict, separation, abuse, or neglect)
• traumatic events or significant emotional losses
• bullying, social isolation, or peer exclusion
• academic pressure and high expectations
• use of psychoactive substances

Particularly vulnerable are adolescents with low self-esteem, pathological perfectionism, and negative cognitive styles, such as a tendency toward self-blame or depressive rumination. Moreover, girls have a higher risk of depression than boys, although boys show a higher rate of completed suicide.

Clinical Manifestations and Diagnosis

Depressive symptoms in adolescence may resemble those in adults, but often present in a more atypical fashion. In addition to classic mood symptoms (sadness, anhedonia, guilt, hopelessness), the following are frequently observed:

• Marked irritability (more common than in adults and sometimes the only sign of psychological distress)
• Social withdrawal and loss of interest in previously enjoyable activities
• Decline in academic performance, difficulties with concentration and decision-making
• Somatic complaints (headaches, abdominal pain, sleep and eating disturbances)
• Substance abuse or self-harming behaviors

A significant proportion of depressed adolescents may go on to develop manic or hypomanic symptoms, falling within the spectrum of bipolar disorders. In severe cases, suicidal thoughts, plans, or attempts may occur, and adolescent depression is one of the leading causes of youth suicide.

Diagnosis is clinical and based on history-taking and behavioral observation. The diagnostic criteria are the same as for adult depressive disorders (Major Depressive Disorder, Bipolar Disorders). It is sometimes supported by screening tools such as the Children's Depression Inventory or the age-adapted Beck Depression Inventory.

Treatment, Prognosis, and Complications

Therapeutic intervention must be prompt and tailored. For mild to moderate cases, psychotherapy is preferred:

• Cognitive-behavioral therapy: to modify dysfunctional thoughts and improve emotional regulation
• Family therapy: useful when parental dynamics or family conflict contribute to the distress

In more severe or treatment-resistant cases, pharmacological therapy with SSRIs (e.g., fluoxetine) may be indicated, but should only be initiated under close psychiatric supervision, given the risk of manic switches or increased suicidal impulsivity in the early phases of treatment.

The prognosis of adolescent depression varies depending on severity, duration, comorbidity, and family support. When treated early, full remission is possible, but the risk of recurrence is high, especially when the disorder is associated with a psychiatric family history or substance abuse.

The most serious complication is Suicide Risk; suicide is the second leading cause of death among 15- to 19-year-olds.

Three main at-risk adolescent profiles have been identified:

• girls with classic depressive symptoms (sadness, anhedonia, apathy)
• boys who are perfectionist, anxious, and socially withdrawn
• boys with impulsive and antisocial behaviors

Warning signs include frequent talk about death, marked behavioral changes, regression, insomnia, appetite loss, giving away personal belongings, or academic decline. In about half of youth suicides, there is recent alcohol or drug use.

Proper care, longitudinal monitoring, and educational and social support are essential to prevent chronicity and reduce suicide risk.

References
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