Questions to ask young male patients about Depressive Disorders

Overview

Under DSM-5, released in May 2013, the three main types of depressive disorders are major depression, persistent depressive disorder and disruptive mood dysregulation disorder.ⁱ

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.¹ 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.² 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.³

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.⁴

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.^5,6

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.⁷ Additional research is needed on how best to incorporate these treatments into primary care practice.

In adolescent males, depressive symptoms and depression are common, with 19% of high school males reporting feeling sad or hopeless,⁸ and 4.6% of 13- to 18-year-old boys having depression.⁹ Males are more likely to die of suicide than females, and sexual minority males have increased risk for suicidal attempts and ideation compared with heterosexual males.¹⁰ This is believed to be attributable to stigma and lack of social support.^{11 (as cited in 12)}

Disruptive mood dysregulation disorder is a new condition introduced in the DSM-5 to address symptoms that had been labeled as “childhood bipolar disorder” before the DSM-5's publication. This new disorder can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme, out-of-control behavior.

Children presenting to clinics with features of disruptive mood dysregulation disorder are predominantly male.  Among community samples, male preponderance appears to be supported. This difference in prevalence between males and females differentiates disruptive mood dysregulation disorder from bipolar disorder, in which there is an equal gender prevalence.¹³

Disruptive mood dysregulation disorder should be differentiated from  disruptive, impulse-control and conduct disorders, discussed below.  However, disruptive, impulse-control and conduct disorders also tend to be more common in males.¹⁴

Treating adolescent depression in the primary care setting is realistic, efficacious, and feasible (Stein, Zitner, & Jensen, 2006). Supportive interventions and active problem-solving with health care professionals may be beneficial, particularly when adolescents are unable to get care outside the primary care setting (Stein et al., 2006). It is important for the primary care clinician (PCC) to have skills to identify depression and provide treatment and referral to a mental health specialist, as appropriate.¹⁵