Depression in Adolescents
Introduction
epression in adolescents is a common but often overlooked mental health issue that can be the reason for disruptive behaviour in school, in relationships, and in daily functioning.
Though being mistaken for a "typical moodiness", adolescents may experience persistent sadness, irritability, and loss of interest, all hallmark symptoms of depression.
Biological factors, such as hormonal changes and interactions with environmental stressors like academic pressure and social challenges, increase risk.
Left unrecognised, adolescent depression can lead to academic decline, substance use, and strained family relationships.
Early identification and understanding of how depression uniquely presents in young people are essential for timely support, accurate diagnosis, and effective intervention tailored to adolescents.
1. Age-Specific Symptoms
Epidemiological data suggest depression onset begins to rise linearly in the early teens up until middle age, with the ‘median age of onset of mood disorders ranging between the late 20s and the early 40s’. <tt>2061</tt>
However, there is a particular challenge with identifying and diagnosing depression in adolescents. In contrast to adults, adolescents may find it much more challenging to articulate and express unprecedented thoughts and emotions they are experiencing.
There may also be an overlap between the ‘typical’ mood changes observed among adolescents as they adapt and manage the biological, cognitive and social changes that are part of their development and the potential symptoms of depression they may also experience. <tt>2053</tt>
A widely used criterion for major depressive disorder (MDD), first published in the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association. Although this criterion is largely the basis on which diagnosis is made today, little mention is made of differences between presentations of major depressive disorder (MDD) between adolescents and adults.
Understanding what differences, if any, at least in the context of proportionality, exist between adolescents and adults could make identification and diagnosis reachable sooner.
A 2019 study compared the symptoms of 355 adults diagnosed with depression against the symptoms of depression experienced by their offspring who were also diagnosed with depression (see figure 1). <tt>2050</tt>
Findings suggest several symptoms, including changes in appetite, weight gain, weight loss, insomnia, and loss of energy, seem to be more present in adolescents than adults.
However, some studies suggest minimal differences between adolescents and adults, particularly when depression becomes more severe. <tt>2062</tt>
Perhaps this reflects the lack of any meaningful difference or, more likely, the need for much more research to be directed towards the issue.
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2. Context-Independent Depression
One of the defining symptoms of major depressive disorder (MDD) is ‘depressed mood most of the day, nearly every day', according to the Diagnostic and Statistical Manual of Mental Disorders.
Though, to what extent does social context affect symptoms of depression, particularly in adolescents, and how can this understanding consequently be used to identify and potentially alleviate major depressive disorder (MDD)?
A 2014 study set out to answer this very question, and its findings suggest a larger proportion of depressed adolescents have symptoms which are context dependent, i.e., symptoms of depression improve in certain social contexts (see figure 3). <tt>2054</tt>
Social settings which had the most positive impact on the mood of depressed adolescents included being with a romantic companion. This social setting also had the least negative impact compared to other social settings.
Being with 'other family' (i.e., besides parents) also had the greatest positive impact on the mood of depressed adolescents. However, this social setting also had the greatest negative impact. Which is a reflection of how influential family can be on our wellbeing, be it good or bad.
However, being alone and being with parents had the least positive impact and the highest negative impact. Perhaps indicating a need for emotional support but from sources unassociated with authority. Which further suggests why 'other family' had a great positive impact.
These studies suggest social contexts could have an impact on either exacerbating or alleviating symptoms of depression in adolescents, despite the overaching and persistent negative moods which hallmark their depression.
3. Growing Out Of It
It is believed that adolescents who experience a higher frequency of depressive symptoms during adolescence will ‘grow out of it’, believing it to be transient and benign.
This is indeed true for some adolescents, though evidence suggests that other adolescents experience recurrence of these depressive symptoms into adulthood, a phenomenon of which evidence suggests existed in adolescents for decades. <tt>2056</tt>
A recent 2013 study analysed data from the Oregon Adolescent Depression Project, which involved examination of 816 participants across four developing periods: childhood (5–12.9 years old), adolescence (13–17.9 years old), emerging adulthood (18–23.9 years old), and adulthood (24–30 years old).
The incidence of first-onset major depressive disorder (MDD) was <u>19%</u> during adolescence (<u>13–17.9 years old</u>). Among participants with a history of major depressive disorder (MDD) in an earlier developmental period, the <u>recurrence rate</u> remained high during <u>emerging adulthood</u> and <u>adulthood</u>, at <u>43%</u> and <u>39%</u>, respectively. <tt>2055</tt>
It is worth noting that, as high quality as this study may be, given the sample size and longitudinal span, 89% of participants were white and from a particular region of Oregon, USA.
One might suspect the first incidence rate and recurrence rate to be higher if the studied population included more adolescents of ethnic backgrounds.
The duration of major depressive disorder (MDD) symptoms must be at least two weeks in order to meet the criteria for depression according to the Diagnostic and Statistical Manual of Mental Disorders 5; though, the average duration of major depressive disorder (MDD) symptoms recorded in this study was 27.7 weeks.
4. Gender Specific Depression
Females, both adults and adolescents, have a higher prevalence of depression in both the developing and developed regions of the world, and this has been the case for decades.<tt>2063</tt><tt>2064</tt>
This epidemiology suggests the driver could be, at least in part, of biological origin, i.e., related to how sex hormones (e.g., oestradiol) interact with emotional regulation centres in the brain or interact with other hormones (e.g., serotonin) associated with those centres.<tt>2058</tt>
However, a recent systematic analysis found the evidence for the contribution of sex hormones in depression in adolescent females to be ‘weak’, due to the high risk of bias in those studies, and therefore the matter, for now, is still inconclusive.<tt>2057</tt>
Studies which investigate the difference in perceived stress between genders, using the Perceived Stress Scale (PSS), do not consistently report significant differences, but when differences are observed in some studies, results suggest women perceive more stress from a given event, possibly explained by being more attuned to the stress of a given event, although the underlying reasons for this disparity remain debated.<tt>2059</tt>
Self-reported coping styles of adolescent students suggest females depend more on emotional-focused coping styles (e.g., emotional support) to a higher extent than males do (see figure 6).<tt>2060</tt>
Unfortunately, evidence suggests that males are less likely to seek help when experiencing mental health challenges, despite much effort in this field.
However, researchers point out this is likely a contributing factor but unlikely to be the main driver behind higher recognised rates of depression in females.
5. Treatment
The first-line treatment for depression in young people (12-17 years old) is psychological therapy, typically cognitive behavioural therapy (CBT), but it can also include interpersonal psychotherapy for adolescents (IPT-A) and non-directive supportive therapy (NDST).<tt>2066</tt>
In severe or persistent cases, a referral to a child and adolescent psychiatrist would be considered, and after assessment and a diagnosis, medication such as a selective serotonin reuptake inhibitor (SSRI) may be prescribed.
The first-line selective serotonin reuptake inhibitor (SSRI) for adolescent depression is fluoxetine, which offers the most optimal balance of efficacy and adverse effect risk profile relative to other antidepressants for adolescents.
These guidelines established by the National Institute for Health and Care Excellence (NICE) also recommend including regular exercise ‘(45 minutes to 1 hour per session, up to 3 times a week) following a structured programme for 10 to 12 weeks’.
Exercise has been shown to have a positive association with adolescent depression, likely due to the release of ‘feel good’ hormones (e.g., endocannabinoids). <tt>2067</tt>
When researchers measure serum endocannabinoids before and after exercise in human participants, results consistently show higher levels post-exercise.
This is colloquially known as a 'runner's high' and could explain why exercise improves mood in both depressed and healthy people.<tt>2068</tt><tt>2069</tt>
Conclusion
Adolescent depression is a complex condition that extends beyond normal developmental mood changes and requires careful recognition.
Because symptoms may present differently than in adults, depression in young people is often misunderstood or missed entirely.
The interaction of emotional, biological, and environmental factors highlights the need for increased awareness among caregivers, educators, and healthcare providers.
When left unaddressed, depression can significantly interfere with an adolescent’s academic performance, relationships, and overall well-being.
Improving understanding of adolescent-specific symptoms and challenges is a crucial step toward earlier identification, appropriate support, and better long-term outcomes for affected individuals.