case study of depression in adolescence

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• v.172(3); 2000 Mar

Evidence-Based Case Review

Identifying and treating adolescent depression, martha c tompson.

1 Department of Psychology Boston University 64 Cummington St Boston, MA 02215-2407

Fawn M McNeil

Margaret m rea.

2 Department of Psychiatry and Biobehavioral Sciences University of California Los Angeles, CA 90095

Joan R Asarnow

• Understand the importance of diagnosing and treating depression in adolescents
• Identify the symptoms of depression in adolescents and the difference between depression and normal adolescent moods
• Identify suicidal risk in a depressed adolescent
• Understand when a specialty consultation is needed
• Understand what effective treatments are available

By age 18, about 20% of our nation's youth will have had depressive episodes, 1 , 2 with girls at substantially higher risk. 2 Major depressive episodes in adolescence last an average of 6 to 9 months, 2 , 3 6% to 10% of depressed adolescents have protracted episodes, and the probability of recurrence within 5 years is about 70%. 3 Given that depressed people are as likely to seek help in primary care settings as in mental health establishments, 4 primary care physicians may be the first to be aware of this problem in their adolescent patients.

Case history

Wanda S, aged 16 years, comes for her checkup accompanied by her mother. She is in good health and has had no notable illnesses in the past year. However, Wanda complains of difficulty sleeping in the past few months and of frequently being tired. Her mother asks for a few minutes alone to discuss her concerns about her daughter. She states that “Wanda has been much more irritable than her usual self” and that “her teachers have been complaining that she doesn't seem to attend to her work lately and her grades are slipping.” Wanda's mother remembers being an unhappy adolescent herself and asks your advice on how to help her daughter.

When directly questioned, Wanda admits to “feeling pretty bad for the last few months, since school began.” She concedes that she feels sad and blue most days of the week and believes that she is “a loser.” She's been spending more time alone and, despite complaining of chronic boredom, has little energy or desire to engage in recreational activities.

Our conclusions are based on literature searches using both MEDLINE and PsychLIT databases, and most are derived from empiric findings and clinical trials. Because of the relatively modest literature, particularly on treatment, some suggestions are based on published opinions of experts. We have noted when expert opinion is our source.

What does depression look like in adolescents?

According to the Diagnostic and statistical manual of mental disorders , fourth edition, 5 an adolescent must have five out of nine characteristic symptoms most of the time for at least 2 weeks for a diagnosis of major depressive disorder. At least one of these symptoms must be either depressed or irritable mood or a pervasive loss of pleasure or interest in events that were once enjoyed. Many seriously depressed adolescents experience both. For example, a depressed adolescent may feel sad most of the day, act crabby, stop hanging out with friends, and seem to lose her love of soccer.

Summary points

• Adolescent depression is common, and primary care physicians are often in a position to first identify the symptoms
• Depression includes changes in moods, thoughts, behaviors, and physical functioning. Among adolescents, depression may include irritable as well as sad moods
• Unlike normal adolescent moods, depression is severe and enduring and interrupts the adolescent's ability to perform in school, to relate to peers, and to engage in age-appropriate activities
• In assessing the risk of suicide, ask straightforward questions about the adolescent's intent, plan, and means
• Antidepressant medication and psychotherapy may be effective treatments; a combination of these is frequently optimal
• Education about depression with both the adolescent and parents provides a rationale for treatment, may alleviate family misunderstandings, and facilitates recovery

Although all adolescents occasionally become sad, and adolescent angst may be normal and common, symptoms of major depression are more severe in intensity, interfere with social, academic, and recreational activities, and last for months at a time, 2 instead of fluctuating like more typical adolescent ups and downs. 6 Depression occurs as a cluster of signs and symptoms, including emotional, physical, and mental changes that usually signify an alteration from the adolescent's normal personality. 3

Some adolescents present with depressive symptoms but do not meet the full criteria for having major depression. Dysthymic disorder is characterized by milder but more persistent symptoms than major depression. In dysthymic disorder, symptoms are present much of the time for at least one year in adolescents (2 years in adults).

Wanda's physician prescribes a low dose of fluoxetine hydrochloride (Prozac), a selective serotonin reuptake inhibitor. In addition, the physician refers Wanda for interpersonal therapy to help her cope with the losses and disappointments of the past year, develop new peer relationships, and reintegrate herself into high school activities.

This multifaceted approach will address the physical and psychological symptoms Wanda has been experiencing and provide her with skills she can use to combat future depressive symptoms and interpersonal problems.

What contributes to adolescent depression?

The vulnerability-stress model is useful for understanding depression. According to this model, adolescent depression results from a predisposition for depression, which is then triggered or complicated by environmental stress. The exact nature of the predisposition may include biologic and cognitive factors. This interplay between life's stresses and cognitive and biologic vulnerabilities is important in conceptualizing depression in an adolescent.

An accumulation of adverse life circumstances and events can trigger depression. Family adversity, 7 academic difficulties, 3 chronic medical conditions, 8 and loss in the adolescent's life may increase risk. As Wanda's history illustrates, losses such as her breakup with a boyfriend and failure to make the track team may serve as triggers. Illnesses such as asthma, sickle cell anemia, irritable bowel syndrome, recurrent abdominal pain, and diabetes mellitus may put an adolescent at particular risk. 8

Cognitive models of depression suggest that it is not stressful events and circumstances but rather the tendency toward negative interpretations about these situations that initiates and maintains depression. 9 , 10 When an adverse event occurs, the depressed adolescent often understands the cause of the event as something stable, internal, and global. For example, Wanda fails to make the track team and attributes this failure to being a “loser.” This cause is stable (unlikely to change), internal (her own fault), and global (affecting everything she does).

Vulnerability to depression may result from biologic or genetic factors and lead to numerous biologic changes. First, studies of family history show that offspring of depressed parents are at high risk for depression 11 and that depressed adolescents have high rates of depression among their family members. 12 Wanda's mother may have been depressed during adolescence. Second, as depressions become more severe, biologic changes may occur, including dysregulation of growth hormone and changes in sleep architecture. 6

How do you assess adolescent depression?

The diagnosis of depression is made clinically. Physicians need to ask about changes in an adolescent's moods, feelings, and thoughts; behaviors; daily functioning; and any impairment in that functioning, as well as physical symptoms. Furthermore, a medical explanation (for example, thyroid disease or adrenal dysfunction) or substance misuse needs to be ruled out as possible causes. The best methods of assessment supplement the adolescent's selfreport with reports from parents or guardians and other outside sources. 2 Whereas youths tend to be better reporters of their internal experiences, such as their mood and thoughts, parents tend to be better reporters of overt behaviors, such as disruptive behavior in the classroom and defiance. 13 As in all primary care evaluations, ethnic and cultural factors must also be considered. For example, in some cultures, making eye contact with an authority figure may not be considered proper etiquette, and the failure to do so may not reflect a depressed mood. 3 In recent years, several screening tools for depression have been adapted for use in primary care settings. 14 , 15 The use of these screening techniques can improve the quality of assessments of depression while reducing the time needed for questioning during routine examinations.

How do you assess and intervene when an adolescent is suicidal?

Depression is associated with a markedly increased risk of suicide and attempted suicide. 16 , 17 , 18 About 41% of depressed youths have suicidal ideation, and 21% report a past attempt at suicide. 2 Although many people are concerned that asking directly about suicide may suggest the idea, most depressed youths have suicidal thoughts and are relieved at the opportunity to share them. Unfortunately, adolescents may not volunteer this information unless directly questioned. Often depressed youths have thoughts of death, a desire to die, or a more overt suicidal intention. Asking straightforward, unambiguous questions to assess the risk of suicide is the best strategy. Questions may include “Have you thought that life was not worth living?” “Have you wished you were dead?” “Have you thought about killing yourself?” “What have you thought about doing?” “Have you ever tried to hurt yourself?” or “Have you ever actually tried to kill yourself?” If there is evidence of suicidal thoughts or attempts, it is then critical to establish if the adolescent has the intent, plan, and means to attempt suicide. Questions to ask may include “Are you going to try?” “How would you do it?” and “Do you have a gun (knife, pills)?”

When is a specialty consultation needed?

Depression in adolescents is frequently complicated by other mental health and life problems. Because these additional problems affect management strategies, it is important to screen for comorbid disorders and problems with psychosocial functioning and life stress. If at any point the primary care physician feels uncertain about the diagnosis and/or management strategy, specialty mental health consultation is recommended. Primary care physicians should obtain a consultation with a specialist if any of the following are present: current or past mania, two previous episodes of depression, chronic depression, substance dependence or abuse, eating disorder, a history of being admitted to a hospital for psychiatric problems, or a history of suicide attempts or concerns regarding the risk for suicide.

TREATMENTS EFFECTIVE FOR ADOLESCENT DEPRESSION

Although research on the treatment of adolescent depression is limited, recent clinical trials have identified promising interventions, both pharmacologic and psychotherapeutic. The physician also needs to help the family to understand the adolescent's symptoms.

Although research has clearly documented the use of antidepressant medication for adults with depression, 19 far fewer studies have examined the use of these agents in adolescents. Selective serotonin reuptake inhibitors are the first choice in medication for depressed adolescents because of their relatively benign side effects, their safety in overdose, and because they only need to be taken once daily. 3 Both tricyclic antidepressants and monoamine oxidase inhibitors are less efficacious in adolescents, are more lethal in overdose, 20 and are not recommended at this time. 3

Cognitive behavior therapies are effective in treating adolescent depression. 21 , 22 They assume that developing more adaptive ways of thinking, understanding events, and interacting with the environment will reduce depressive symptoms and improve a youth's ability to function. The cognitive component of the treatment focuses on helping adolescents identify and interrupt negative or pessimistic thoughts, assumptions, beliefs, and interpretations of events and to develop new, more positive or optimistic ways of thinking. The behavioral component focuses on increasing constructive interactions with others to improve the likelihood of receiving positive feedback.

Interpersonal therapy emphasizes improving relationships. The therapy is brief and focuses on the problems that precipitated the current depressive episode. It helps the adolescent to reduce and cope with stress. Two studies 23 , 24 have shown its effectiveness in reducing depression.

No definitive guidelines have been published for deciding when to begin with medication, psychotherapy, or a combination of medication plus psychotherapy. We have, however, suggested several considerations based on common sense to help clinicians make this decision. 25 , 26 , 27 For example, medication should be considered if an adolescent does not seem interested in thinking about problems, has limited cognitive abilities, is severely depressed with vegetative symptoms, has had two or more episodes of depression, has not responded to 8 to 12 weeks of psychotherapy, or cannot regularly get to therapy sessions. Conversely, psychotherapy should be considered as the first alternative for adolescents who fear medication or do not like taking pills, prefer talking about problems, have complex life stressors that need sorting out, have contraindications to medication (such as pregnancy or breast-feeding), or have not responded to an adequate trial of medication. For some adolescents who have combinations of severe depression, limited cognitive skills, and complex life stressors, it may be best to begin with both medication and psychotherapy.

Parents may have little understanding of the adolescent's symptoms and sometimes interpret falling grades and lack of interest as willful behavior. By giving parents information about the symptoms, causes, and treatments of depression, the physician can help them to help their child to recover, to monitor symptoms, and to facilitate ongoing care. 3 Families differ in their willingness to consider the possibility that their child may have a psychological or psychiatric problem. For personal and/or cultural reasons, some families may be more receptive to a medical model, which identifies the depressive symptoms as part of an illness, and so they are more comfortable with a pharmacologic intervention. Other families may find a cognitive explanation more acceptable and see psychotherapy as a more palatable option. Further, primary care physicians may note that on finding out about their adolescent's depression, parents may feel guilty or feel they are being blamed and thus be resistant to suggestions for interventions. Appropriate education about depression and possible causes may help allay these concerns.

Symptoms of major depressive disorder in adolescents

• Depressed or irritable mood
• Loss of pleasure or interest in activities that were once enjoyed
• Significant weight loss or gain when not dieting, or an increase or decrease in appetite
• Insomnia or hypersomnia
• Observable slowing of movements and speech or increased agitation
• Feelings of worthlessness or excessive and/or inappropriate guilt
• Difficulty concentrating and/or making decisions
• Recurrent thoughts of death or suicide or a suicide attempt
• For a diagnosis, an adolescent must have at least 5 symptoms, which must include at least one of either of the first 2 symptoms, for at least 2 weeks.

When assessing adolescents for depression who already have chronic illnesses, it is important to look at the symptoms that are less likely to overlap with the physical illness, such as feelings of guilt, worthlessness, and hopelessness. It may be difficult to decipher whether changes in sleep patterns, appetite, and increased fatigue are due to the illness or to depression. 3

Symptoms of dysthymic disorder in adolescents

Depressed or irritable mood must be present for most of the day, more days than not, for at least 1 year. In addition, 2 of the following 6 symptoms must be present:

• Poor appetite or overeating
• Low energy of fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

During this time, the adolescent has never been without the depressive symptoms for more than 2 months at a time but does not meet criteria for a major depressive episode.

Having assessed thoughts of death, the intention to die, plans for an attempt, the means to commit suicide, and the availability of support, the physician must estimate the degree of risk and make choices for managing the patient's risk of suicide. 3 First, although thoughts of death or thinking of suicide in vague terms suggests a low risk, such symptoms indicate a need for both immediate intervention and close monitoring (because suicidal risk can increase). Second, when the adolescent acknowledges having a plan or means but no intent, emergency care may not be needed if safety can be ensured through involving parents and other support systems. Parents need to be in close proximity and to remove potential means such as firearms, and the adolescent needs to be referred for psychotherapy. However, if the adolescent does not have a supportive family, has access to lethal means, or has other risk factors (for example, a past suicide attempt, family history of suicide, recent exposure to suicide, substance abuse, bipolar illness, mixed state, or severe stress), more intensive interventions are needed, and the adolescent needs to see a mental health specialist. Finally, when the adolescent has intent, plan, and means, the risk for suicide is high. Such adolescents need help immediately, and psychiatric emergency care may be needed. 3 Regardless of risk, follow-up care is essential to tackle the concerns that contributed to the adolescent's suicidal feelings.

Empirically supported treatment options

Selective serotonin reuptake inhibitors Alters dysfunctional neurotransmitter systems

Cognitive behavioral therapy Monitors and changes dysfunctional ways of thinking

Interpersonal therapy Improves interpersonal skills and problem-solving abilities

Funding: National Institutes of Health, Agency for Health Care Policy and Research

SHELLEY S. SELPH, MD, MPH, AND MARIAN S. MCDONAGH, PharmD

Am Fam Physician. 2019;100(10):609-617

Patient information: See related handout on depression in children and adolescents , written by the authors of this article.

Author disclosure: No relevant financial affiliations.

The prevalence of major unipolar depression in children and adolescents is increasing in the United States. In 2016, approximately 5% of 12-year-olds and 17% of 17-year-olds reported experiencing a major depressive episode in the previous 12 months. Screening for depression in adolescents 12 years and older should be conducted annually using a validated instrument, such as the Patient Health Questionnaire-9: Modified for Teens. If the diagnosis is confirmed, treatment should be initiated for persistent, moderate, and severe depression. Active support and monitoring may be sufficient for mild, self-limited depression. For more severe depression, evidence indicates greater response to treatment when psychotherapy (e.g., cognitive behavior therapy) and an antidepressant are used concurrently, compared with either treatment alone. Fluoxetine and escitalopram are the only antidepressants approved by the U.S. Food and Drug Administration for treatment of depression in children and adolescents. Fluoxetine may be used in patients older than eight years, and escitalopram may be used in patients 12 years and older. Monitoring for suicidality is necessary in children and adolescents receiving pharmacotherapy, with frequency of monitoring based on each patient's individual risk. The decision to modify treatment (add, increase, change the medication or add psychotherapy) should be made after about four to eight weeks. Consultation with or referral to a mental health subspecialist is warranted if symptoms worsen or do not improve despite treatment and for those who become a risk to themselves or others.

The prevalence of depression is increasing among youth in the United States. The 2005 to 2014 National Surveys on Drug Use and Health, which included 172,495 adolescents 12 to 17 years of age, found that the percentage of adolescents who experienced one or more major depressive episodes in the previous 12 months increased from 9% in 2005 to 11% in 2014. 1 In 2016, this percentage was approximately 13% (5% in 12-year-olds, 13% in 14-year-olds, and 17% in 17-year-olds), and although 70% of youths experienced severe impairment from depression, only about 40% received treatment. 1 Treatment rates have changed little since 2005, raising concern that adolescents are not receiving needed care for depression. 1

Risk Factors

Increased risk of depression in children and adolescents may be due to biologic, psychological, or environmental factors ( Table 1 ) . 2 – 34 In children 12 years and younger, depression is slightly more common in boys than in girls (1.3% vs. 0.8%). 35 However, after puberty, adolescent girls are more likely to experience depression. 35

Screening for Depression

The U.S. Preventive Services Task Force (USPSTF) recommends screening children and adolescents 12 to 18 years of age for major depressive disorder with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 36 The American Academy of Family Physicians supports the USPSTF recommendation. 37 In 2018, the American Academy of Pediatrics endorsed the Guidelines for Adolescent Depression in Primary Care (GLAD-PC), which recommends screening adolescents 12 years and older annually for depressive disorders using a self-report screening tool. 38 , 39

There are various instruments to screen adolescents for depression. One popular instrument for use in primary care is the Patient Health Questionnaire-9: Modified for Teens (also called PHQ-A) for patients 11 to 17 years of age. The PHQ-A is shown in Figure 1 and Table 2 , along with four questions not used in scoring that address suicidality, dysthymia, and severity of depression. 40 , 41

Clinical Presentation

The presenting sign of major depressive disorder may be insomnia or hypersomnia; weight loss or gain; difficulty concentrating; loss of interest in school, sports, or other previously enjoyable activities; increased irritability; or feeling sad or worthless. 42 To distinguish between normal grief, such as after the loss of a loved one, and a major depressive episode, it may be helpful to determine whether the predominant symptom is a sense of loss or emptiness (more typical of grief) vs. a persistent depressed mood with the inability to anticipate future enjoyable events (more typical of depression). 42

When a child or adolescent screens positive using a formal screening tool, such as the PHQ-A, or when he or she presents with symptoms indicating a possible depressive disorder, the primary care physician should assess whether the symptoms are a result of a major depressive episode or another condition that could present with similar symptoms. To diagnose major depressive disorder, criteria from the Diagnostic and Statistical Manual of Mental Disorders , 5th ed. (DSM-5), must be met and not explained by substance abuse, medication use, or other medical or psychological condition. 42 The full DSM-5 criteria are available at https://www.aafp.org/afp/2018/1015/p508.html#afp20181015p508-t6 . Some children may develop a cranky mood or irritability rather than sadness.

Medical conditions that may present similarly to depression include hypothyroidism, anemia, autoimmune disease, and vitamin deficiency. Laboratory tests that may be helpful in ruling out common medical conditions that could be mistaken for depression include complete blood count; comprehensive metabolic profile panel; an inflammatory biomarker, such as C-reactive protein or erythrocyte sedimentation rate; thyroid-stimulating hormone; vitamin B 12 ; and folate.

Other psychological conditions that may present similarly to major depressive disorder include persistent depressive disorder (also called dysthymia) and disruptive mood dysregulation disorder. If a child or adolescent has a depressed mood for more days than not for at least one year, the diagnosis may be persistent depressive disorder, which is often treated the same as a major depressive episode (e.g., antidepressants, psychotherapy). 42 If a child or adolescent is predominantly angry with temper outbursts, the diagnosis may be disruptive mood dysregulation disorder or posttraumatic stress disorder. 42

Symptoms of bipolar disorder, eating disorders, and conduct disorders may also overlap with major depressive disorder. Children and adolescents may have more than one psychiatric diagnosis concurrently, such as comorbid depression and anxiety. According to the Centers for Disease Control and Prevention, 74% of children three to 17 years of age who have depression also have anxiety, and 47% of children with depression also have a behavior problem. Therefore, a thorough assessment is needed, with possible mental health consultation or referral.

Risk Assessment for Suicide

Suicide is the second leading cause of death for people 10 to 24 years of age after unintentional injury. 43 Depression is a risk factor for suicide, but at-risk youth can be easily missed without specific suicide screening. In one study, nurses in a pediatric emergency department used the Ask Suicide-Screening Questions (ASQ) tool to assess suicide risk in 970 adolescents who presented with psychiatric problems. 44 Of those who screened positive, 53% did not present with suicide-related problems. The sensitivity and specificity for a return visit to the emergency department because of suicidality within six months were 93% and 43%, respectively, for a positive predictive value of 10% and a negative predictive value of 99%. 44 The ASQ screening test is shown in Figure 2 . 45 The complete ASQ toolkit is available at https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml#outpatient .

INITIAL MANAGEMENT

The GLAD-PC guidelines recommend that primary care physicians counsel families and patients about depression and develop a treatment plan that includes setting specific goals involving functioning at home, at school, and with peers. 38 For example, a treatment plan might include treating others with respect, attending family meals, keeping up with schoolwork, and spending time in activities with supportive peers. Additionally, a safety plan should be established that limits access to lethal means, such as removing firearms from the home or locking them up. It should also provide a way for the patient to communicate during an acute crisis (e.g., providing phone numbers for people to contact if suicidal thoughts occur, creating a list of coping skills, educating the parents on how to recognize if the patient is a risk to self or others). 38 If the danger of suicide becomes imminent, psychiatric evaluation in a hospital emergency department or psychiatry crisis clinic is needed.

For mild depression, which may be short-lived, primary care physicians should consider active support such as counseling about depression and treatment options, facilitating caregiver/patient depression self-management, and monitoring the patient every week or two for six to eight weeks before initiating pharmacotherapy and/or psychotherapy. 46 – 50 According to the DSM-5, although the symptoms of mild depression are distressing, they are manageable and result in only minor impairment in functioning, whereas severe depression causes more seriously distressing, unmanageable symptoms that greatly impact functioning. See Figure 3 for a suggested approach to the management of depression in children and adolescents. 43 , 50

ONGOING MANAGEMENT

Treatment options for children and adolescents with depression include psychotherapy and anti-depressants. Cognitive behavior therapy (CBT) is a form of talk therapy that focuses on changing behaviors by correcting faulty or potentially harmful thought patterns and generally includes five to 20 sessions. Whereas CBT focuses on cognition and behaviors, interpersonal psychotherapy concentrates on improving interpersonal relationships and typically includes around 12 to 16 sessions.

Fluoxetine (Prozac) and escitalopram (Lexapro) are the only two medications approved by the U.S. Food and Drug Administration to treat major depressive disorder in children and adolescents. Fluoxetine is approved for patients eight years and older, and escitalopram is approved for patients 12 years and older. There are concerns of increased suicidality with the use of fluoxetine and escitalopram in this population. 51 Although there were no suicides in trials of children and adolescents taking antidepressants, suicidal thoughts and behaviors were increased compared with placebo (4% vs. 2%). 51 Children and adolescents who are taking these medications should be monitored for suicidality. The frequency of monitoring should be based on the individual patient's risk (e.g., weekly monitoring at treatment onset, monthly monitoring in a child showing steady improvement on antidepressants).

PHARMACOTHERAPY ALONE

Three systematic reviews of randomized controlled trials including children and adolescents with major depressive disorder support the use of fluoxetine as the first-line antidepressant medication. 52 – 54 Two reviews also support the use of escitalopram as initial therapy. 52 , 54 However, the effects of fluoxetine and escitalopram as monotherapy were often similar to placebo, depending on the outcome measured. Tricyclic antidepressants, other selective serotonin reuptake inhibitors, and serotonin-norepinephrine reupta ke inhibitors have not been shown to be effective in treating depression in children and adolescents. 46 , 52 – 54 If neither fluoxetine nor escitalopram is effective and antidepressant therapy is desired, referral to a child or adolescent psychiatrist is recommended.

PSYCHOTHERAPY ALONE

Evidence is mixed for the use of CBT as monotherapy in children and adolescents with depression. A systematic review for the USPSTF found no benefit of CBT on remission or recovery and inconsistent effects on symptoms, response, and functioning. 54 One trial of youth with major depression who declined antidepressants found that compared with self-selected treatment as usual, 12 weeks of CBT was associated with shorter time to treatment response and remission and improved depression scores through week 52 but not in weeks 53 to 104. 55 In children and adolescents with subclinical depression, one systematic review (19 trials) found moderate-quality evidence that CBT is associated with a small effect on depressive symptoms vs. waitlist or no treatment. 56

COMBINED THERAPY

Evidence from a good-quality randomized trial suggests that adolescents are most likely to achieve remission with 12 weeks of combined therapy with fluoxetine and CBT (37%; number needed to treat = 4) compared with either therapy alone (23% with fluoxetine; number needed to treat = 11; 16% with CBT) or placebo (17%). 47 , 57 Suicidality declined with duration of treatment for all therapies, but the decline was less steep for fluoxetine alone (26.2% at baseline to 13.7% at week 36) vs. combination therapy (39.6% to 2.5%) and CBT alone (25.2% to 3.9%). 47 , 57

In another trial of adolescents who achieved at least a 50% decrease in depression scores following six weeks of fluoxetine treatment, those who were randomized to receive the addition of CBT to fluoxetine therapy for six months were less likely to relapse at 78 weeks compared with continued fluoxetine monotherapy (36% vs. 62%). 58

Children and adolescents with moderate or severe depression or persistent mild depression should be treated with fluoxetine or escitalopram in conjunction with CBT or other talk therapy. 47 , 57 – 59 If combination therapy is not used, monotherapy with an antidepressant or psychotherapy is recommended, although the likelihood of benefit is lower. 46 , 52 – 56

Reassessing Treatment and Treatment Duration

One trial found that early reassessment of depression is valuable. 43 In this study, all youth received interpersonal psychotherapy and were randomized to a four- or eight-week follow-up assessment for treatment modification. If additional treatment was needed because of inadequate response, patients were further randomized to add-on fluoxetine or more intense (twice weekly) psychotherapy. Those who were reassessed at four weeks improved the most at 16 weeks (a difference of 5.7 points on the Hamilton Rating Scale for Depression; scores on this scale can range from 0 to 58 points, with a score of 0 to 7 considered normal and a score of 20 associated with moderate depression; P < .05). Additionally, those who began add-on fluoxetine at four weeks had better posttreatment depression scores than those who began intense interpersonal psychotherapy at eight weeks, although there was no difference in global assessment scores between the two groups.

Treatment duration for talk therapy in adolescents with unipolar depression is typically six months or less, but longer treatment may be necessary. Although good evidence regarding the duration of medication treatment in adolescents with depression is lacking, the GLAD-PC guidelines recommend continuing medication for one year beyond the resolution of symptoms. 50

Referral to a Mental Health Subspecialist

If a child or adolescent does not improve after initial treatment for depression, the primary care physician may add, change, or increase a medication and may consider referral for psychotherapy. Referral to a licensed mental health professional is appropriate at any point in the treatment process. However, if the depression does not improve or the child deteriorates even with treatment, consultation with or referral to a child or adolescent psychiatrist is necessary.

This article updates previous articles on this topic by Clark, et al. 60 ; Bhatia and Bhatia 61 ; and Son and Kirchner . 62

Data Sources: We conducted general and targeted searches using Essential Evidence Plus, Ovid Medline, PubMed, the Cochrane Database of Systematic Reviews, the U.S. Preventive Services Task Force, the Agency for Healthcare Research and Quality, and UpToDate, including the key words children or adolescents with depression. Search dates: November 2018 to January 2019, and September 27, 2019.

The authors thank Alycia Brown, MD, for her review of the manuscript and Ngoc Wasson, MPH, and Chandler Weeks, BS, for help with formatting the manuscript.

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• Published: 07 August 2023

A global mental health approach to depression in adolescence

• Ana Paula Donnelly 1  

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Adolescence is one of the most important transition periods in life, in which self-esteem and identity are being shaped and individuals experience profound social and physical transformations. In recent years, a concerning increase in the prevalence of mental health disorders in adolescents has been documented, prompting the mental health research community to prioritize understanding the risks of developing psychiatric disorders as well as factors that might be protective. Nature Mental Health spoke about depression in adolescence with Christian Kieling , an associate professor of child and adolescent psychiatry at the School of Medicine at the Federal University of Rio Grande do Sul in Brazil. Kieling is leading an international project called ‘Identifying depression early in adolescence ( IDEA )’ that brings a global health approach to the topic.

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Depression in adolescence: a review

• Diogo Beirão   ORCID: orcid.org/0000-0001-5612-8941 1 ,
• Helena Monte 1 ,
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• Alice Longras 1 ,
• Carla Matos 1 , 2 &
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Depression is a common mental health disease, especially in mid to late adolescence that, due to its particularities, is a challenge and requires an effective diagnosis. Primary care providers are often the first line of contact for adolescents, being crucial in identifying and managing this pathology. Besides, several entities also recommend screening for depression on this period. Thus, the main purpose of this article is to review the scientific data regarding screening, diagnosis and management of depression in adolescence, mainly on primary care settings.

Comprehension of the pathogenesis of depression in adolescents is a challenging task, with both environmental and genetic factors being associated to its development. Although there are some screening tests and diagnostic criteria, its clinical manifestations are wide, making its diagnosis a huge challenge. Besides, it can be mistakenly diagnosed with other psychiatric disorders, making necessary to roll-out several differential diagnoses. Treatment options can include psychotherapy (cognitive behavioural therapy and interpersonal therapy) and/or pharmacotherapy (mainly fluoxetine), depending on severity, associated risk factors and available resources. In any case, treatment must include psychoeducation, supportive approach and family involvement. Preventive programs play an important role not only in reducing the prevalence of this condition but also in improving the health of populations.

Depression in adolescence is a relevant condition to the medical community, due to its uncertain clinical course and underdiagnosis worldwide. General practitioners can provide early identification, treatment initiation and referral to mental health specialists when necessary.

Adolescence is an important period in developing knowledge and skills, learning how to manage emotions and relationships and acquiring attributes and abilities for adulthood. Depression in adolescence is a common mental health disease with a prevalence of 4–5% in mid to late adolescence [ 1 ]. It is a major risk factor for suicide and can also lead to social and educational impairments. Consequently, identifying and treating this disorder is crucial.

General practitioners and primary care providers are frequently the first line of contact for adolescents in times of distress and can be crucial to identify mental health issues amongst these patients. They can facilitate early identification of depression, initiate treatment and refer the adolescents for mental health specialists [ 2 ]. It is vital to make a timely and accurate diagnosis of depression in adolescence and a correct differential diagnosis from other psychiatric disorders, due to the recurrent nature of this condition and its association with poor academic performance, functional impairment and problematic relationships with parents, siblings and peers. Furthermore, depression at this age is strongly related to suicidal ideation and attempts [ 2 ].

The US Preventive Services Task Force (USPSTF) recommends screening adolescents for depressive disorder by the General Practitioners [ 2 , 3 ]. Guidelines from the American Academy of Pediatrics (AAP) state that adolescent patients should be screened annually for depression in Primary Care with a formal self-report screening tool [ 4 ]. AAP recommends that Primary Care clinicians should evaluate for depression in those who screen positive on the screening tool, in those who present with any emotional problem as the chief complaint and in those in whom depression is highly suspected despite a negative screen result [ 4 ].

The present work consists of a review on the depression in the adolescent, summarizing data published in scientific papers in the last years, regarding the epidemiology of the disease, its pathogenesis and risk factors, screening and diagnosis tools and its management and treatment. Our research focused on research papers published between January 2010 and March 2020 in the area. Other research papers not included in this first search were included due to their interest and value to the subject. The keywords, used in different permutations and combinations, included the following: depression, adolescence, overview, pathophysiology, diagnosis and treatment.

Epidemiology

The prevalence of depression is significantly linked to age, being low in children (< 1%) and increasing throughout childhood and adolescence. Nevertheless, the prevalence of depression in adolescence varies significantly between studies and reports. A reported prevalence in Great Britain was 4%, whereas in the USA was 2.1% and in France was 11.0% [ 5 , 6 , 7 ]. Nevertheless, a systematic review from 2013 stated the life prevalence of depression varies from 1.1 to 14.6% [ 8 ].

A possible factor for the reported increase during adolescence is the set of social and biological changes characteristic of post-pubertal phase, such as enhanced social understanding and self-awareness, brain circuits changes involved in responses to reward and danger and increased reported stress levels [ 9 , 10 , 11 ].

Regarding differences between genders, while no significant differences are found in depression during childhood, depression during adolescence has a strong female preponderance, similar to adulthood [ 12 , 13 , 14 ]. This difference is still observed between distinct epidemiological and clinical samples and across various methods of assessment. As such, it is unlikely due to differences in help-seeking or reporting of symptoms and more closely tied to female hormonal changes, which suggests a direct link to hormone-brain relations [ 15 ].

Pathogenesis

Comprehension of the pathogenesis of depression in adolescents is a challenging task, due to its heterogeneous clinical presentation and diverse causes.

Putative risk factors, potentially modifiable during adolescence without professional intervention, are substance use (alcohol, cannabis and other illicit drugs, tobacco), diet and weight [ 16 ].

Alcohol use is known to have neurotoxic effects during this developmentally sensitive period. Cannabis and other illicit drugs can have an impact on serotonin and other neurotransmitters causing an increase in depressive symptoms. Furthermore, alcohol, cannabis and other illicit drug use have various deleterious social and academic consequences for the adolescent which could increase their risk for depression [ 16 ].

The relationship between tobacco use and depression is unclear. However, it has been proposed that this linkage may arise from the effects of nicotine on neurotransmitter activity in the brain, causing changes to neurotransmitter activity [ 17 ]. Overweight can have a negative impact on self-image which elevates the risk for depression. Moreover, depressed people may lead a less healthy lifestyle and suffer from deregulation in the stress response system, which may contribute to weight gain [ 16 ].

Association between depression and environmental factors, such as exposures to acute stressful events (personal injury, bereavement) and chronic adversity (maltreatment, family discord, bullying by peers, poverty, physical illness), has been subject of papers. Stressful life events seem more strongly associated with first onset rather than recurrence, and risk is considerably greater in girls and in adolescents who have multiple negative life events. The most important factors are chronic and severe relationship stressors [ 18 ]. A significant interaction was found between exposure to maternal threatening behaviours and deficits in emotional clarity in relation to depressive symptom severity [ 19 ].

Genetic factors can also play a very important role in the pathogenesis. Many reports suggest that a variant (5-HTTLPR) in the serotonin transporter gene might increase the risk of depression, but only in the presence of adverse life stressors or early maltreatment. The findings are less robust in adolescent boys than girls. This gene variant has also been reported to affect fear-related and danger-related brain circuitry, which is altered in depression. However, such findings seem to vary not only by genotype but also by age, sex, and severity of symptoms, and are also reliant on good quality measures of adversity and depression [ 18 , 20 ].

Two interrelated neural circuits and associated modulatory systems have been closely linked to risk for depression. One circuit connects the amygdala to the hippocampus and ventral expanses of the prefrontal cortex (PFC) and is linked to hypothalamic-pituitary-adrenal (HPA) axis activity. Disruption of this circuit links depression to stress-related enhancements in HPA-stress systems, such as higher than expected cortisol concentrations, and activity in the serotonergic system. Psychosocial stress, sex hormones and development have also been linked to changing activity in this circuit, with evidence that this circuit matures after adolescence. High concentrations of sex steroid receptors have been identified within this circuit and might provide a biological mechanism for why girls have higher risk of depression than boys. The other key circuit implicated in depression encompasses the striatum and its connection to both the PFC and ventral dopamine-based systems. Like the first circuit, this one also continues to mature through adolescence. Sex differences emerge in both circuits. Research into this reward circuit implies that reduced activity is linked with expression of and risk for depression. Reduced striatal and PFC activity during tasks involving rewards has been recorded both in individuals with major depression and in those with depressed parents. Both inherited factors and stress-related perturbations seem to contribute to these changes [ 18 , 21 ].

Temperament and character traits are also important factors in the pathogenesis of depression in adolescence. According to Cloninger, temperament is responsible for automatic and emotional responses to environmental stimuli and encompasses four dimensions: novelty seeking, exploratory activity, harm avoidance, reward dependence and persistence [ 22 ]. In contrast, character develops across the lifespan and is influenced by social and cultural experiences. Three dimensions are distinguished: self-directedness, cooperativeness and self-transcendence [ 23 ]. Studies showed that depressed patients present higher novelty seeking, harm avoidance and lower reward dependence, persistence, self-directedness and cooperativeness compared to healthy individuals [ 23 , 24 ].

Primary care providers are frequently the first contact during times of distress and can be crucial to identify mental health issues allowing for an earlier depression diagnosis, treatment and referral [ 2 ].

The symptoms can differ from the adult population. In comparison to it, adolescents tend to have more frequently somatic symptoms, anxiety, disruptive behaviour and personality disorders [ 25 ].

The fact that these symptoms are common in other disorders such as hypothyroidism, anaemia, sleep apnoea or other chronic diseases makes the diagnosis more challenging to establish in these subjects [ 26 ].

Screening tools

The screening of adolescents for depression is an essential tool for early detection of this disorder. USPSTF and AAP recommend the screening of adolescents in primary care settings [ 2 , 3 , 4 , 25 , 26 , 27 ].

The Beck Depression Inventory (BDI) and Patient Health Questionnaire for Adolescents (PHQ-A) are the most commonly used, outperforming other screening tools in the identification of major depressive disorder among adolescents [ 2 , 28 ].

Originally developed as a depression symptom rating scale for the adult population, BDI is widely used among adults and adolescents and mainly in research. It is a 21-item self-report measure of depressive symptoms, scored from “0” to “3”. Participants are asked to respond to each item based on their experiences within the past 2 weeks. The total score can range from 0 to 63, with higher scores meaning higher levels of depressive symptoms [ 29 ]. In primary care settings, an adapted version (BDI-PC) is often used, which consists of a 7-item self-report instrument, with a cut-off of 4 points for major depression [ 30 ]. Good performance has also been shown using BDI, with sensitivity ranging from 84 to 90% and specificity ranging from 81 to 86% [ 3 ].

The PHQ-A is the depression module of a 67-item questionnaire that can be used to screen for depression among adolescent primary care patients. Composed of 9 questions, it can be entirely self-administered by the patient and evaluates symptoms experienced in the 2 weeks prior. It measures functional impairment and inquiries about suicidal ideation and suicide attempts [ 31 ]. The PHQ-A study had the highest positive predictive value, as well as a sensitivity and specificity of 73% and 94%, respectively [ 3 ].

Diagnostic tools

Diagnosis of depression in adolescents is established through the criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [ 32 ]. The evaluation of patients should be made through interviews, alone and with the patient’s family and/or caregivers and should include an assessment of functional impairment in different domains and other existing psychiatric conditions [ 4 ].

DSM-5 establishes the diagnosis of major depressive disorder as a period of at least 2 weeks during which there is a depressed mood or the loss of interest or pleasure in nearly all activities, and, additionally, at least four additional symptoms from a list that includes changes in weight, sleep disturbances, changes in psychomotor activity, fatigue, feelings of worthlessness or guilt, impaired concentration or ability to make decisions, or suicidal ideation. Additionally, it states that, in adolescents, depressed mood can be replaced by irritability or crankiness, a sign that can be neglected during assessment or by caregivers. This presentation should be differentiated from a pattern of irritability when frustrated [ 33 ]. Children diagnosed with disruptive mood dysregulation disorder, a new diagnosis referring persistent irritability and frequent episodes of extreme behaviour, typically develop unipolar depressive or anxiety disorders as they mature into adolescence [ 32 ]. Clinical presentation differs between genders, with female adolescents reporting feelings of sadness, loneliness, irritability, pessimism, self-hatred and eating disorders, while males present with somatic complaints, reduced ability to think or concentrate, lacking decision making skills, restlessness and anhedonia [ 34 , 35 ].

The severity of depressive disorders can be based on symptom count or intensity, and/or level of impairment. Mild depression can be defined as 5 to 6 symptoms that are mild in severity, with mild impairment in functioning. Severe depression exists when a patient experiences all depressive symptoms listed in the DSM-5 or severe impairment in functioning and, also, with at least 5 criteria and a specific suicide plan, clear intent or recent suicide attempt, psychotic symptoms or family history of first-degree relatives with bipolar disorder. Moderate depression falls between these two categories [ 4 ].

Differential diagnosis

Despite its well-defined diagnostic criteria, depression during adolescence can often be misdiagnosed, with the main differential diagnoses being adjustment disorder, dysthymic disorder, bipolar disorder and schizophrenia. However, it is crucial to establish the correct diagnosis as different psychiatric disorders involve distinct treatment and prognosis.

Adjustment disorder is classified as depressed mood in response to an identifiable psychosocial stressor. It arises within 3 months of the onset of a stressor and persists up to 6 months after stressor resolution. It is characterized by low mood, tearfulness, or hopelessness associated with a significant distress that exceeds what would be expected given the nature of the stressor, or impaired social or occupational functioning. On the other hand, dysthymic disorder is a pattern of chronic symptoms of depression that are present for most of the time on most days with a minimum duration of 1 year for children and adolescents [ 32 ].

Bipolar disorder and schizophrenia are much less common in adolescents compared to depression disorder. However, they have different prognosis and require different treatments. Consequently, when establishing the diagnosis of depressive disorder in adolescence, it is important to bear in mind that the first symptomatic episode may also represent the beginning of a bipolar disorder [ 36 , 37 ].

Management and treatment

The treatment of depression in adolescence can include psychotherapy, pharmacotherapy or both [ 38 ]. Treatment should be selected based on the severity of the condition, the preference of the patient/family, associated risk factors, family support and the availability of each therapy [ 39 , 40 ]. On first approach, it is essential to comprehensively explain the therapeutic strategy and involve both patients and family members to assure close follow-up of progress, treatment adjustment according to symptoms and prevention of relapse [ 41 ]. Adolescents with moderate to severe depression, substance abuse, psychiatric disorders, suicidal ideation or resistance to treatment should be referred for specialized evaluation [ 42 ].

Treatment may be divided into three phases: acute (obtain response and remission), continuation (consolidate the response) and maintenance (avoid recurrences) [ 39 ]. Each of them must include psychoeducation, supportive approach and family involvement [ 39 , 40 ].

In mild depression, psychotherapy may be the first option, complemented with pharmacotherapy if there is no response [ 42 , 43 ]. The AAP recommends starting with active support, symptom monitoring and close follow-up for 6–8 weeks [ 44 ]. These measures are also useful when patients refuse more interventional treatments. The National Institute for Health and Care Excellence (NICE) has a slightly stricter approach, in which it recommends psychotherapy after absence of improvement after 2 weeks of watchful waiting [ 45 ]. In adolescents with moderate to severe depression, treatment is based on combined psychotherapy and pharmacotherapy [ 42 , 43 ]. NICE recommends psychotherapy for the minimum of 3 months, followed by fluoxetine if necessary. AAP has a similar approach [ 44 , 45 ]. Other strategies such as physical exercise, sleep hygiene and adequate nutrition have been referred as treatment adjuvants [ 44 , 46 , 47 ].

Both NICE and AAP recommend treatment for at least 6 months after remission of symptoms to consolidate the response and prevent relapse (continuation phase). In addition, both organizations also recommend maintaining follow-up during 1 year or, in cases of recurrent depression, 2 years [ 44 , 45 ].

Psychotherapy

In this area, Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) have shown effectiveness [ 40 , 48 ].

CBT is a brief psychotherapy, carried out individually or in groups, based on the relationship between thoughts, feelings and behaviours [ 40 ]. CBT focuses on cognitive distortions associated with depressive mood and the development of behavioural activation techniques, coping strategies and problem solving [ 42 ]. When used in acute depression, it has been shown to have a moderate effect [ 40 ]. CBT seems to be useful in preventing relapses and suicidal ideation, in the treatment of resistant depression and in adolescents with long-term physical conditions [ 49 , 50 , 51 ]. Moreover, the combination of psychotherapy and pharmacotherapy, in particular fluoxetine, has shown promising results [ 52 ]. Within the different psychotherapy approaches, behavioural activation, challenging thoughts and involvement of caregivers have a higher success rate [ 53 ].

IPT assumes depression association with disruptive relationships, based on the negative impact of symptoms on interpersonal relationships and vice-versa [ 40 ]. This approach may be useful especially when there is a well-established relational factor as the cause of the depressive condition [ 54 ]. Most studies have compared only IPT with placebo groups or with other psychotherapy, showing favourable results for IPT [ 48 , 55 ].

Psychotherapy should be considered first line of treatment in adolescents afraid of or with contraindications for medication, with identified stress factors or those with poor response to other approaches [ 56 ]. There are no contraindications to psychotherapy, though it has a limited effect in cases of cognitive delay [ 40 ].

Pharmacotherapy

Even though psychotherapy is an important component, pharmacotherapy can be used as an addition. When psychotherapy is not available or cannot be applied, pharmacotherapy can be an alternative [ 39 , 41 ].

Fluoxetine is widely regarded as the first-line drug for this age group given its efficacy [ 2 , 38 , 57 , 58 , 59 ]. Besides fluoxetine, escitalopram has also shown to be particularly effective, especially for ages between 12 and 17 years [ 38 , 60 , 61 , 62 ]. The main side effects of selective serotonin receptor inhibitors (SSRIs) include abdominal pain, agitation, jitteriness, restlessness, diarrhoea, headache, nausea and changes in sleep patterns. However, these effects are dose dependent and tend to decrease over time [ 39 ].

Given the efficacy of fluoxetine and escitalopram, many studies have focused on other SSRIs, such as sertraline, citalopram, paroxetine and fluvoxamine. Citalopram must be carefully evaluated as side effects include prolongation of the QT interval, which can lead to arrhythmia [ 63 , 64 ]. Paroxetine and fluvoxamine are not commonly used due to a lack of efficacy in this age group [ 65 , 66 ]. Regarding serotonin noradrenaline receptor inhibitors (SNRIs), venlafaxine appears to have a similar efficacy to SSRIs in resistant depression and no significant differences in adverse effects [ 49 ]. However, because hypertension is a possible side effect, this parameter must be periodically evaluated [ 41 , 64 ]. In Table 1 , the main drugs used in the treatment of depression in adolescents are displayed.

Bupropion and duloxetine have also been studied as alternatives but the evidence of its use in adolescents is limited. Bupropion can be useful in the treatment of overweight patients or those who intend to quit smoking. The main side effects are insomnia, agitation and seizures [ 41 ]. Bupropion is contraindicated in patients suffering from eating disorders. Duloxetine can be used for comorbid depression and pain in adolescents [ 67 ].

Tricyclic antidepressants do not have any demonstrated benefit in the treatment of depression in adolescents [ 42 , 68 , 69 ]. This drug class has significant side effects such as dry mouth, orthostatic hypotension, tremors and vertigo and can increase PR interval and QRS duration. Moreover, it is highly lethal in overdose [ 69 ].

At the time of writing, only fluoxetine (ages 8 years and older) and escitalopram (ages 12 years and older) are approved by the Food and Drug Administration for the treatment of depression in children and adolescents [ 70 , 71 ].

Several studies suggest an association between antidepressants and increased suicidal risk [ 18 , 58 ]. However, the risks and benefits of this strategy should be evaluated. Adolescents should be closely monitored, and, if suicidal thoughts arise during treatment, parents should seek care as soon as possible, to adjust dosage, change antidepressant or discontinue it [ 42 ].

Finally, the treatment strategies proposed in this age group are illustrated in Fig. 1 .

Algorithm for the management and treatment of depression in adolescents

Prevention is crucial to depression management, consequence of the impact on the population and inequal quality health care access [ 72 ]. In addition, it prevents the onset of other possible comorbidities, as well as reduces the impact on the patient and their families [ 73 , 74 , 75 ].

It is important to understand which different risk factors and protective factors intervene in the development of the disease. The risk factors can be divided into specific and non-specific for depression. Regarding the specific ones, parent depression history increases the risk between 2 and 4 times [ 76 ]. Among the non-specific, poverty, domestic violence and child abuse also increase the risk. On the other hand, protective factors are good family support, emotional skills or coping ability [ 77 ].

Depression prevention can be divided into 3 types: universal, selective and indicated. Universal interventions target the adolescent population group in general. Selective interventions target adolescents who are at risk for developing depression. Finally, indicated interventions target adolescents with subclinical symptoms of depression [ 78 ].

With regard to universal interventions, the efficacy of prevention programs through therapy for problem solving and overcoming traumatic situations has been demonstrated in multiple studies [ 79 , 80 ]. Although it has been shown that adolescents under these programs experience decreased depressive symptoms, the long-term usefulness of these programs was not unanimous. The inclusion of parents to these programs provided no additional advantage [ 81 ]. Furthermore, no significant difference between adolescents who received an intervention program and those who did not was found, although improvements in school environment were reported [ 82 ].

Concerning selective interventions, interpersonal communication skills and optimistic thinking programs have shown to be effective in decreasing anxiety and depression [ 83 ]. Contrary to universal interventions, the inclusion of parents in programs was demonstrated as beneficial [ 83 , 84 , 85 ]. However, it had no benefit to adolescents, but improved the parents’ perception of children’s behaviour [ 86 ].

Finally, in indicated interventions, psychoeducation and skill development programs to overcome interpersonal issues and role disputes among adolescents have been carried out [ 87 , 88 ]. It was shown that symptoms improved significantly compared at the end of the program [ 87 ]. Additionally, the number of adolescents with suicidal ideations decreased.

Comparing different groups of programs, various meta-analyses have found that selective and indicated programs are more effective than universal ones [ 89 , 90 ]. These prevention programs are more effective when started between the ages of 11 and 15 [ 78 ]. However, their superiority is not unanimous [ 91 ].

Depression in adolescence can be a complex diagnosis and requires individual and oriented treatment. For this reason, early identification, treatment initiation and prompt referral to mental health specialists is crucial for the prognosis of these patients.

Due to the variety of its main clinical manifestations and the lack of diagnostic tests that fully and accurately establish the definite diagnosis, this process can be particularly challenging. Additionally, several differential diagnoses must be made to provide an accurate course of treatment.

Treatment options can include both psychotherapy (CBT or IPT) and pharmacotherapy. The most promising results are observed with the combination of psychotherapy and pharmacotherapy, mainly fluoxetine.

Nevertheless, the authors would like to highlight certain aspects that require improvement and implementation in daily practice in comparison with the presented recommendations in this publication. First, although Cognitive Behavioral Therapy is one of the most studied therapeutic orientations, the reproducibility of performance among professionals is limited and relies on the relationship established between the mental health professional and the patient, in a deeper way compared to pharmacotherapy. The scarce number of professionals and the absence of choice by the user may not allow the development of this interpersonal bond. This limitation is particularly important in the case of children and adolescents, who are in a period of transition in their physical and mental development, and whose psychological intervention can have a significant positive or negative impact with potential future repercussions. Second, most of the prevention programs described in the literature are not currently implemented. Finally, approaching the family environment is essential in the implementation of effective long-term therapeutic interventions, especially in the presence of a dysfunctional structure. Although recommended, its practical application is often difficult due to the need of active participation of family members, inside and outside the clinical office. Prevention, early diagnosis and treatment of depression in adolescence should be considered worldwide objectives, and the implementation of straightforward, effective and cost-conscious strategies for achieving such purposes is essential. Amongst these objectives, prevention is of utter importance and must be a priority when defining political strategies and governmental programs related to mental health.

Availability of data and materials

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Abbreviations

US Preventive Services Task Force

American Academy of Pediatrics

Prefrontal cortex

Hypothalamic-pituitary-adrenal

Beck Depression Inventory

Patient Health Questionnaire for Adolescents

Beck Depression Inventory for Primary Care

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Cognitive Behavioral Therapy

Interpersonal Therapy

Selective Serotonin Reuptake Inhibitors

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The authors would like to thank Dilermando Sobral, MD, Sónia Almeida, MD and Paula Assunção, MD for their guidance.

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DB conceived the original idea of this work and took the lead in writing the manuscript. All authors contributed equally in the literature review and writing of the manuscript. DB was responsible for the section on epidemiology and comorbidities. HM was responsible for the sections on the background and pharmacological treatment. MA was responsible for the abstract, non-pharmacological treatment and the conclusion. AL was responsible for the sections on methods and pathogenesis. CM was responsible for the sections on diagnosis and background, and FVB for the section on prevention. DB and HM were responsible for the construction of the final version of the manuscript which was reviewed and approved by all co-authors.

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Beirão, D., Monte, H., Amaral, M. et al. Depression in adolescence: a review. Middle East Curr Psychiatry 27 , 50 (2020). https://doi.org/10.1186/s43045-020-00050-z

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• Adolescence

A closer look into the affect dynamics of adolescents with depression and the interactions with their parents: An ecological momentary assessment study

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• Published: 18 May 2024

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• Loes H.C. Janssen   ORCID: orcid.org/0000-0003-3543-6026 1 , 2 ,
• Bart Verkuil 1 , 2 ,
• Lisanne A.E.M. van Houtum 1 , 2 ,
• Mirjam C.M. Wever 1 , 2 ,
• Wilma G.M. Wentholt 1 , 2 &
• Bernet M. Elzinga 1 , 2  

Adolescents with depression tend to perceive behavior of parents as less positive than adolescents without depression, but conclusions are based on retrospective reports assessed once or over long time intervals, with the risk of memory biases affecting the recall. The current study used ecological momentary assessments to examine the link between adolescent affect and the amount of warmth and criticism expressed by both mothers and fathers in families with adolescents with depression versus adolescents without psychopathology in daily life. It also explored the possible bias by assessing parenting on the momentary, daily (EMA), and retrospective level. The sample consisted of 34 adolescents with depression and 58 parents and 80 healthy controls and 151 parents (adolescents: M age = 15.8, SD  = 1.41; 67.5% girls, parents: M age = 49.3, SD  = 5.73; 54.1% mothers). Participants completed retrospective questionnaires and four surveys a day for 14 consecutive days. Preregistered multilevel models showed that momentary parenting reports of adolescents with depression and healthy controls did not differ. The associations between perceived parenting of both mothers and fathers and adolescent affect did also not differ between the two groups. These results illustrate that adolescents generally benefit from supportive parenting, but substantial differences between individuals were found. In contrast to the momentary data, both adolescents with depression and their parents did report more negative parenting on retrospective questionnaires than healthy controls and their parents indicating that adolescents with depression may have a negativity bias in their retrospective recall. These findings are highly relevant for clinical practice and underscore the need for careful assessments on different time scales and including all family members.

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The prevalence of mood disorders increases substantially during adolescence [ 1 ] and an early onset has been associated with higher recurrence rates [e.g., 2 ] and adverse psychosocial outcomes in adulthood [e.g., 3 ]. One of the key interpersonal factors that affects adolescent well-being is the relationship with parents [ 4 ]. Findings based on observational and retrospective self-report studies showed that a lack of warmth and critical parenting are related to depression in adolescents, but also that adolescent depression can impact parenting [ 5 , 6 , 7 ]. These studies, however, mainly focused on retrospective reports on parenting and may involve recall bias [ 8 ] which may be amplified for adolescents with depression [ 9 ]. Moreover, these studies focused on how families differed in their levels of parenting (between-family level), while parenting can change from day to day, and each family is unique with distinct parent-adolescent dynamics [ 10 , 11 ]. Zooming in to the daily and moment-to-moment experiences of parent-adolescent interactions and the associations with the adolescent affect can provide valuable insights for clinical interventions. By using ecological momentary assessment [EMA; 12 ] we aimed to examine the link between parental warmth and criticism of mothers and fathers and adolescent affect in families with adolescents with depression (i.e., a current major depressive disorder (MDD) or dysthymia; DEP) and families with adolescents without psychopathology (i.e., healthy controls; HC). Additionally, we explored the possible impact of recall bias on parenting reports by assessing parenting on the momentary, daily level (both based on EMA), and a more global, retrospective level (using questionnaires).

Parent-adolescent interactions characterized by lack of warmth and support and elevated levels of conflict and criticism have been consistently linked to depression in adolescents [e.g., 5 , 6 , 7 , 13 ] and depression later in life [ 14 , 15 , 16 ]. Most of this evidence, however, is based on retrospective self-report questionnaires assessed once or spanning large time intervals (e.g., last year). To overcome potential reporter bias, observational studies have been used to gain insights into the more fine-grained dynamics between parents and adolescents. These studies show that low levels of parental positivity relate to depression in children and adolescents, but findings are more mixed, probably also due to the variety of tasks and coding systems [see for review 17 ]. Still, an important limitation here is that it does not capture the daily life dynamics in a natural context in which parent-adolescent interactions occur [ 8 ]. Recent studies have shown that parenting is highly dependent on the context and can fluctuate over time (i.e., hours or days) within a family or person [ 18 , 19 , 20 ], but research addressing these everyday family dynamics in clinical samples of adolescents is limited.

To date, 12 EMA studies investigated affect in adolescents with a clinical depression [see review 21 ]. Some studies found that adolescents with mood disorders report lower levels of positive affect and higher levels of negative affect than healthy controls [ 22 , 23 ], but others did not find differences in affect between depressed and non-depressed adolescents [ 24 , 25 , 26 ]. While EMA enables assessing the naturalistic dynamic setting of adolescents’ daily life, only three studies examined the social context (i.e., amount of time spent together or co-rumination with peers or family) of adolescents with depression [ 23 , 27 , 28 ]. Quality of time spent together with parents was, however, not assessed. This is an important omission, given the importance of parenting for adolescent well-being [e.g., 5 , 6 ]. As a next step, we therefore examined whether momentary positive and negative affect as well as momentary parental warmth and criticism (from both adolescents’ and parents’ perspective) during parent-adolescent interactions differed between families with a DEP adolescent and families with a HC adolescent. Moreover, we compared parenting reports between families with DEP adolescents and HCs on different time scales: momentary, daily, and retrospective, to explore whether a recall bias [ 8 ] may influence parenting reports.

Previous studies in community samples have shown that on moments or days when adolescents perceive more parental warmth and less parental conflict, they report less negative affect and more positive affect [ 29 , 30 , 31 ]. Moreover, the strength of this association may differ between adolescents explained by depressive symptoms. For adolescents who reported more depressive symptoms, stronger associations were found between (a lack of) daily parental support and conflict and adolescent negative affect compared to adolescents who reported less depressive symptoms [ 29 , 30 ]. On the momentary level, depressive symptoms only explained differences in associations over time [ 31 ]. For instance, adolescents with more depressive symptoms experienced a stronger increase in positive affect after a warm interaction with their parent. Although these studies provided some first insights, it is essential to include a clinical sample to investigate whether this also holds in adolescents with clinical depression, which is important for the ultimate goal of guiding clinical practice.

This preregistered study ( https://osf.io/qjyp5 ) aimed to (1) examine whether adolescent momentary positive and negative affect and momentary parental warmth and criticism during parent-adolescent interactions differed between families with a DEP adolescent and HCs, (2) assess the within-person momentary association between perceived parenting behavior and affect during parent-child interactions, and (3) examine whether this association is stronger for DEP adolescents. We hypothesized that: 1a) DEP adolescents report less momentary positive and negative affect than HCs; 1b) DEP adolescents and (1c) their mothers and fathers report less parental warmth and more parental criticism during momentary parent-child interactions than HCs; 2) more perceived parental warmth and less perceived parental criticism of mothers and fathers at a given moment is associated with more positive and less negative affect at the same moment; 3) the associations between perceived parenting of mothers and fathers and adolescent affect during momentary parent-adolescent interactions are stronger for DEP adolescents compared to HCs. After preregistration, we added an exploratory aim: comparing parenting reports on the momentary, daily level (both based on EMA), and retrospective level (questionnaires) of families with DEP adolescents and HCs.

Data were used from RE-PAIR (Relations and Emotions in Parent Adolescent Interaction Research), which examines parent-adolescent interactions and adolescent mental well-being by comparing DEP adolescents and their parents to HC adolescents and their parents. The RE-PAIR study consisted of four parts: online questionnaires, a research day at the lab, two weeks of EMA, and an Magnetic Resonance Imaging (MRI)-scan session with the adolescent and one parent. The current study focused on the EMA part of RE-PAIR and also included several online questionnaires. The RE-PAIR study was approved by the Medical Ethics Review Committee (METC) of Leiden University Medical Centre (LUMC; research protocol: P17.241).

Families were included in the study if adolescents: were aged between 11 and 17 years when screened for psychopathology, started secondary school, lived with at least one primary caregiver who wanted to participate, and had a good command of the Dutch language. Participation with two parents – if possible – was preferred but this was no requirement. DEP adolescents had to meet criteria for a current MDD or dysthymia as primary diagnosis, and no other primary (neuro)psychiatric disorder or comorbid psychosis, substance use disorder or mental retardation. For HC adolescents, a lifetime MDD/dysthymia diagnosis, a current mental disorder, or a history of psychopathology in the last two years were exclusion criteria. Adolescent psychopathology was assessed with the Kiddie-Schedule for Affective Disorders and Schizophrenia – Present and Lifetime Version [K-SADS-PL; 32 ]. All participants signed informed consent. If adolescents were younger than 16 years of age, parents with legal custody also signed informed consent for the adolescent. For detailed information on sample recruitment and study procedure see Appendix 1 .

In total, 114 families participated in the EMA of RE-PAIR: 80 HCs and their 151 parents, and 34 DEP adolescents and their 58 parents. Current primary diagnosis was MDD for 28 adolescents (82.4%) and dysthymia for 6 adolescents (17.6%). See Appendix 2 for comorbidity of adolescents and psychopathology of parents. Due to a branching error in questionnaires of one HC adolescent, we excluded that family resulting in a final sample of 79 HCs and 149 parents. Table  1 provides sample demographics. The majority of adolescents (96.3% HCs; 91.2% DEP adolescents) and parents (94.6% parents of HCs; 82.8% parents of DEP adolescents) were born in the Netherlands.

All participants received four questionnaires a day for 14 consecutive days (56 in total) on the Ethica app on their own smartphone. Questionnaires were triggered between 7AM and 9.30PM on weekdays and 9AM and 9.30PM on weekend days according to a standardized trigger schedule (detailed information in Appendix 3 and full codebook of EMA: https://osf.io/dcemq/ ). The EMA of RE-PAIR was conducted between September 2018 and March 2022. As compensation for EMA, parents received €20,- and HCs received €10,-. DEP adolescents did not receive compensation for the EMA since the assessments were considered as valuable information that could generate new insights and potentially facilitate the treatment due to possible self-insight. Treatment was not part of RE-PAIR and took place in regular clinical outpatient settings. To limit potential confounding influence of treatment, families who received parenting interventions or family-based treatment were not able to participate in RE-PAIR. Additionally, six gift vouchers of €75,- were raffled among all participating families based on compliance of EMA questionnaires completed by the family.

DEP adolescents fully completed 1193 (63.8%) of the delivered questionnaires and answered on average 35.1 questionnaires ( SD  = 13.9, range 11–55). In 554 cases (46.4% of answered questionnaires), adolescents indicated that they had interacted with one or both parents who participated in the EMA of RE-PAIR ( M  = 16.3 parent-adolescent interactions per participant, Range = 2–33). Parents fully completed 2329 (72.8%) of the delivered questionnaires and answered on average 40.2 questionnaires ( SD  = 9.7, range 11–53).

HCs fully completed 2930 (68.3%) of the delivered questionnaires and answered on average 37.1 questionnaires ( SD  = 11.2, range 3–55). In 1426 cases (48.7% of answered questionnaires), adolescents indicated that they had interacted with one or both parents who participated in the EMA of RE-PAIR ( M  = 18.1 parent-adolescent interactions per participant, Range = 3–42). This did not differ significantly from DEP adolescents ( p  = .334). Parents fully completed 6582 (80.5%) of the delivered questionnaires and answered on average 44.2 questionnaires ( SD  = 8.2, range 16–56). No participants were excluded based on missing data and all completed EMA data was retained for analyses.

Momentary positive and negative affect . Adolescents rated their momentary affect using an adapted and shortened four-item version of the Positive and Negative Affect Schedule for Children [PANAS-C; 33 , 34 ]. Two positive affect states (happy and relaxed) and two negative affect states (sad and irritated) were assessed by asking “How do you feel at this moment?” followed by: “Happy”, “Relaxed”, “Sad”, and “Irritated”. Answers were given on a 7-point Likert type scale ranging from 1 ( not at all ) to 7 ( very ). An average score of the two positive affect states was calculated, with the two items being strongly correlated at the between person-level, r  = .830, p  < .001, and moderately at the within-person level, r  = .463, p  < .001. An average score of the two negative affect states was calculated, with the two items being strongly correlated at the between person-level, r  = .765, p  < .001, and moderately at the within-person level, r  = .335, p  < .001. See Appendix 4 for correlations.

Momentary positive and negative affect during parent-adolescent interaction . Adolescents were asked with whom they spoke last to or with since the last beep and could select parents, friends, others, or no one. If they indicated they spoke last to or with mother, father or both follow-up questions were asked about this interaction. Adolescents rated their momentary affect during the interaction with an adapted and shortened five-item version of the Positive and Negative Affect Schedule for Children [PANAS-C; 33 , 34 ]. Two positive affect states (happy and relaxed) and three negative affect states (sad, irritated, and guilty) were assessed by asking “How did you feel during this contact?” followed by: “Happy”, “Relaxed”, “Sad”, “Irritated”, and “Guilty”. Guilt, often part of or accompanying adolescent depression [ 35 ], was only assessed after interactions since parents and parenting can induce guilt during interactions [ 5 ]. Answers were given on a 7-point Likert type scale ranging from 1 ( not at all ) to 7 ( very ). For the current study, only answers about interactions with parents who participated in the EMA were included. An average score of the two positive affect states was calculated, with the two items being strongly correlated at the between person-level, r  = .838, p  < .001, and moderately at the within-person level, r  = .428, p  < .001. An average score of the three negative affect states was calculated, with the three items being strongly correlated at the between person-level, range r  = .543–0.670, p  < .001, and moderately to low at the within-person level, range r  = .161–0.335, p  < .001. See Appendix 4 for correlations.

Parenting during parent-adolescent interaction. Adolescents rated parenting behavior during the interaction, if they indicated that they spoke last to or with their parent(s), by answering the questions “How well did your mother/father listen to you?”, “How well did your mother/father understand you?”, “How critical was your mother/father towards you?”, and “How dominant was your mother/father?”. Answers were given on a 7-point Likert type scale with answer categories ranging from 1 ( not at all ) to 7 ( very ).

Similarly, if parents indicated that they spoke last to or with their adolescent since the last beep, they rated their own parenting behavior during the interaction. They answered the questions “How well did you listen to your child”, “How well did you understand your child?”, “How critical were you towards your child?”, and “How dominant were you towards your child?”. Answers were given on a 7-point Likert type scale with answer categories ranging from 1 ( not at all ) to 7 ( very ). Two subscales were created for parents and adolescents separately, parental warmth and parental criticism. An average score of listening and understanding behavior during the interaction was calculated to assess parental warmth, with the two items being strongly correlated at the between person level, range r  = .763–0.949, p  < .001 and moderately to strongly at the within-person level, range r  = .415–0.697, p  < .001. An average score of critical and dominant behavior during the interaction was calculated to assess parental criticism, with the two items being strongly correlated at the between person level, range r  = .520–0.724, p  < .001 and strongly at the within-person level, range r  = .562–0.657, p  < .001. See Appendix 4 for correlations.

Daily parenting . In the last questionnaire of each day, adolescents indicated whether they spoke to a parent during that day and with whom (i.e., mother, father, stepmother, stepfather). Adolescents rated daily parenting for each parent they spoke to by answering the questions: “Throughout the day, how critical was your mother/father towards you?” and “Throughout the day, how warm/loving was your mother/father towards you?” Answers were given on a seven-point Likert type scale ranging from 1 ( not at all ) to 7 ( very ). Similarly, parents indicated whether they spoke to the participating adolescent in the last questionnaire of each day. Parents rated their own behavior by answering the questions “Throughout the day, how critical were you towards your child?” and “Throughout the day, how warm/loving were you towards your child?” Answers were given on a seven-point Likert type scale with answer categories ranging from 1 ( not at all ) to 7 ( very ).

Depressive symptoms . The Patient Health Questionnaire [PHQ-9; 36 ] was used to assess adolescent depressive symptoms the past two weeks as part of the online questionnaires adolescents had to complete before the research day in the lab. The items are based on nine DSM-IV criteria for depression and are rated as 0 ( not at all) to 3 ( nearly every day ). One item (item 8; moving or speaking slowly or being so fidgety or restless) was split in two items and the maximum score of these two items was included. Sum scores range from 0 to 27 and a score above 10 is suggestive of the presence of depression [ 37 ]. Cronbach alpha was 0.94.

Parental bonding. To assess the parent-adolescent bond, adolescents completed the Dutch version of the Parental Bonding Inventory [PBI; 38 ] as part of the online questionnaires. Adolescents reported on the bond with mothers and fathers separately and only reports about parents who participated in the EMA were included. The instrument consisted of 25 items and included three subscales: care (12 items), overprotection (6 items), and lack of autonomy (7 items) [ 39 ]. Answers were given on a 4-point Likert scale ranging from 0 ( very like ) to 3 ( very unlike ). Since wording of one item of lack of autonomy subscale deviated from the original PBI and showed inconsistent loading [ 39 ], we excluded the item from the subscale in the current study. After reverse coding 13 items, a sum score per subscale was calculated and higher scores indicated more care, overprotection, and lack of autonomy. Cronbach’s alphas in the current sample regarding care, overprotection, and lack of autonomy with mothers were α = 0.88, α = 0.62, and α = 0.82 respectively. Regarding care, overprotection, and lack of autonomy with fathers Cronbach’s alphas were α = 0.87, α = 0.59, and α = 0.71 respectively.

In order to also assess the parent-adolescent bond from the perspective of parents we rephrased the items of the PBI. Cronbach’s alphas for PBI of parents were α = 0.77 for care, α = 0.58 for overprotection, and α = 0.64 for lack of autonomy.

Childhood emotional maltreatment. To assess experienced childhood emotional maltreatment, adolescents filled out the Dutch version of the Childhood Trauma Questionnaire short form as part of the online questionnaires [CTQ-SF; 40 , 41 ]. The full CTQ-SF consists of 25 items including five subscales. The current study uses two subscales: emotional abuse and emotional neglect. Both subscales consist of five items and were answered on a Likert scale, ranging from 1 ( never true ) to 5 ( very often true ). Five items were reverse coded before calculating a sum score per subscale. Higher scores indicating more experienced childhood emotional maltreatment. Overall, the CTQ-SF has been shown to have high reliability and validity [ 41 , 42 ]. Validity in an adolescent sample has also been shown [ 43 ]. In the current sample Cronbach’s alphas were α = 0.82 for emotional abuse and α = 0.84 for emotional neglect.

Preregistered analyses

Our analysis plan, including power analyses, was preregistered online ( https://osf.io/qjyp5 ). As the amount of observations of interactions of adolescents with fathers was less than expected, we performed some sensitivity checks (see Appendix 5 ). For the analyses we used R version 4.0.1 [ 44 ] and for the multilevel package version 2.6 with ML estimation. Level 1 predictors were person-mean centered, following guidelines proposed by [ 45 ] and [ 46 ].

To account for the nestedness of the data (i.e., measurements nested in individuals) we used multiple multilevel models. We ran two-level models instead of three-level models (moments nested in days nested in individuals) as some adolescents on some days did not or once indicated an interaction with their parent(s). To examine whether adolescent momentary positive and negative affect (in general and during parent-adolescent interactions) and momentary parental warmth and criticism during parent-adolescent interactions differed between families with a DEP adolescent and HCs (aim 1) we tested eight models including adolescents’ reports and four including parents’ reports. Although not preregistered, we also compared momentary, daily, and retrospective reports of parenting between the two groups to explore recall bias using multilevel models (momentary and daily level) and appropriate non-parametric tests (retrospective reports). To investigate the within-person association between perceived parenting behavior and adolescent affect during parent-adolescent interactions (aim 2), we added the person-mean centered scores of perceived maternal warmth, perceived maternal criticism, perceived paternal warmth, and perceived paternal criticism to the unconditional random intercept models of positive and negative affect separate (eight models). Next, in each model, variation was allowed around the slope to examine heterogeneity. Likelihood ratio tests were used to assess differences in fit of the models [following guidelines of 47 ]. To assess whether the association between parenting and adolescent affect during parent-adolescent interactions was stronger for DEP adolescents (aim 3), we added the binary variable clinical status (0 = HCs, 1 = DEP adolescents) to the model as main effect and in interaction with perceived parenting. Lastly, we explored whether the association between parenting and adolescent affect during parent-adolescent interactions was stronger for adolescents with more depressive symptoms. This level 2 predictor was grand-mean centered.

Correlation structure corCAR1 was added in all models to take into account unequally spaced time intervals [ 48 ].

Differences between DEPs and HCs

Descriptive statistics of the study variables and results of multilevel models are presented in Table  2 (see Appendix 6 for correlations). DEP adolescents reported significantly less momentary positive and more negative affect than HCs ( p’ s < 0.001, see Fig.  1 ). During parent-adolescent interactions, DEP adolescents reported significantly less positive and more negative affect than HCs ( p ’s < 0.001, see Fig.  2 ). DEP adolescents did not differ from HCs in their perceptions of perceived parental warmth and parental criticism of mothers and fathers during parent-adolescent interactions (all p ’s > 0.050, see Fig.  2 ). Similarly, mothers’ and fathers’ own perception of parental warmth and criticism did not differ between parents of DEP adolescents and HCs (all p ’s > 0.050).

Average fluctuations of momentary positive and negative affect of adolescents over time per group, HC adolescents and DEP adolescents

Average fluctuations of momentary adolescent affect and perceived parenting during parent-adolescent interactions per group over time (observations). Panel A and B represent interactions with mothers reported by HC adolescents and DEP adolescents respectively. Panel C and D represent interactions with fathers reported by HC adolescents and DEP adolescents respectively

On the daily level, DEP adolescents reported lower levels of perceived parental warmth of mothers and fathers than HCs ( p ’s < 0.05, see Table  1 ), whereas levels of perceived criticism did not significantly differ. Parents’ self-reported daily parental warmth and criticism (assessed at the end of the day) did not significantly differ between the two groups. Retrospectively, using appropriate non-parametric tests, DEP adolescents reported higher levels of parental emotional abuse and neglect during their childhood compared to HCs ( p ’s < 0.001) and less care and more overprotection from mothers and fathers than HCs ( p’ s < 0.01). Parents of DEP adolescents also reported less care, more overprotection, and more lack of autonomy compared to parents of HCs ( p ’s < 0.05).

Within-person associations

As indicated by the intraclass correlations (ICC) 57.4% of the variance in adolescent negative affect and 60.8% of the variance in adolescent positive affect was due to differences between adolescents, and 42.6% and 39.2% due to within-person fluctuations over time. Examination of the within-person association between perceived parenting behavior and affect during momentary parent-adolescent interactions (aim 2) showed that when adolescents perceived their mothers and fathers to show more warmth or less criticism during interactions, they also reported more positive and less negative affect (all p ’s < 0.001, see Appendix 7 ). Next, we allowed variation around the slope of perceived parenting in each model and likelihood ratio tests indicated that this improved the model fits significantly (all p ’s < 0.001), This indicates that adolescents differed substantially in the extent to which perceived parental warmth and criticism of mothers and fathers were associated with positive and negative affect.

To examine whether the association between perceived parenting and adolescent affect during momentary parent-adolescent interactions differed between DEP adolescents and HCs (aim 3), we added clinical status (being diagnosed with depression or not) to the models as well as an interaction of clinical status with perceived parenting. Results are displayed in Table  3 . In all models, there was no significant interaction between perceived parenting and clinical status, indicating that the link between perceived parenting and adolescent affect did not differ between DEP adolescents and HCs (see Appendix 8 for figures). Further inspection of these associations in DEP adolescents indicated that even within this group, there are individual differences in how parenting and adolescent affect are related. This is illustrated in Fig.  3 in which individual associations between parental warmth of mothers and negative affect during momentary parent-adolescent interactions were plotted for DEP adolescents.

Individual-level associations between parental warmth of mothers and negative affect during momentary parent-adolescent interactions for DEP adolescents. Each line represents one person

We furthermore explored whether the association between parenting and adolescent affect during parent-adolescent interactions differed based on severity of depressive symptoms instead of clinical status. Findings were similar compared to clinical status and indicated that the link between perceived parenting and adolescent affect during parent-adolescent interactions did not differ between adolescents based on the severity of depressive symptoms. Full model results are presented in Appendix 9 .

Sensitivity analyses

In addition to our preregistered analyses, we conducted three post hoc sensitivity analyses. First, to tease apart within- from between-person associations, we calculated the person-mean of perceived parenting and added the grand-mean centered score to the model including perceived parenting and clinical status. Average perceived parenting was significantly associated with adolescent affect (all p ’s < 0.01) in all models. Results on daily perceived parenting and clinical status did not change from previous models (see Appendix 10 ). Second, to control for the possible influence of time, we added the observation variable (a count variable ranging from 1 to 56) to the models including perceived parenting and clinical status (see Appendix 11 ). Results on daily perceived parenting and clinical status remained the same, but time was a significantly related with adolescent positive affect ( p ‘s < 0.01) except in the model with parental criticism of fathers. Third, to elucidate whether the association between perceived parenting and adolescent affect during parent-adolescent interactions differed between boys and girls, we included perceived parenting, clinical status (as main effect), sex, and an interaction between sex and perceived parenting in the models. The interaction between sex and perceived parenting was not significant, indicating that the link between perceived parenting and adolescent affect did not differ between boys and girls (see Appendix 12 for full model results). Sex itself was also not significantly related to adolescent positive and negative affect in the models including maternal warmth and criticism. However, when inspecting the models focusing on the interactions between adolescents and fathers, adolescent girls reported less positive and more negative affect than boys during interactions with their fathers (all p ’s < 0.050).

We examined the moment-to-moment experiences of adolescent affect and parenting during parent-adolescent interactions in a clinical sample of families with DEP adolescents in comparison to families with HCs. In line with our preregistered hypotheses and some previous research [ 22 , 23 ], we found that DEP adolescents experienced lower levels of positive affect and higher levels of negative affect than HCs throughout the days as well as during parent-adolescent interactions. As illustrated in Fig.  1 , on average DEP adolescents reported little below the middle of the scale (ranging from not at all to very) which may indicate a more flat or blunted affect. This seems to be partly in line with the Emotion Context Sensitivity theory that proposes that depression flattens emotions in general [ 49 ].

In contrast to our hypotheses, momentary levels of reported parental warmth and criticism during parent-adolescent interactions did not differ between the two groups, not from the perspective of the adolescent nor from the parent (i.e., mother and father). On a daily level, parental criticism did not differ between the two groups, but DEP adolescents did perceive their parents to be less warm. Moreover, adolescents with DEP also perceived their relationship with mothers and fathers as more negative (e.g., less care, more overprotection, more emotional abuse and neglect) as indicated on the retrospective questionnaires compared to HCs. Parents of DEP adolescents themselves also reported less parental care and more overprotection on the retrospective questionnaires than parents of HCs. These discrepancies are intriguing, with the retrospective reports being in line with previous findings based on retrospective questionnaires (and observations in the lab) that also indicate that parent-adolescent interactions in families with DEP adolescents are less supportive and more conflictual [e.g., 17 , 50 ] and lower in parental care [ 15 , 51 ]. Thus, findings on retrospective questionnaires do not necessarily match momentary assessments [ 18 ]. When adolescents are asked to report retrospectively on parenting, their memories may be negatively biased by their mood [ 9 ]. Parents of DEP adolescents have shown to be more worried about their child and question their own parenting abilities [ 52 ], which may explain differences in momentary versus retrospective parenting report of parents. Assessing parenting at the momentary level with EMA may reduce these biases.

Our findings furthermore indicate the important association between parenting and adolescent’s well-being, also for DEP adolescents. When adolescents perceived their parents as more warm or less critical during interactions they also reported more positive and less negative affect, or vice versa, supporting previous findings in community samples at the momentary [ 31 ] or daily level [ 29 , 30 ]. The momentary associations between parenting and affect in the current study did not differ between HCs and DEP adolescents. A recent study on parenting and affect during momentary parent-adolescent interactions, based on a community sample, reported similar results [ 31 ]. The abovementioned biases may play a role here as daily reports of parenting still involve some recollection, including the inherent biases, while these do not apply to momentary assessments.

Another important finding is that we found substantial variation between adolescents, indicating that the strength or direction of how warm or critical parenting is associated to adolescent affect differs between adolescents. Even within our sample of DEP adolescents, this heterogeneity was observed, showing that the association between parental warmth and criticism differed between DEP adolescents. This aligns with a previous finding also showing different patterns in adolescents who report clinically relevant depressive symptoms [ 29 ]. Studies using more person-centered and idiographic approaches are needed [ 53 ] to better understand these patterns and translate them into implications for clinical practice.

A unique feature of the current study was that we assessed parental warmth and criticism of mothers and fathers separately. Despite family system theories proposing adolescent-mother and adolescent-father dyads being distinct subsystems [ 6 , 54 ] and suggestions that parenting roles of mothers and fathers may differ [e.g., 55 ], not many studies have assessed parenting of both mothers and fathers. Our results suggest that perceived parental warmth and criticism of mothers and fathers are important for adolescent well-being. Interestingly, sensitivity analyses (in the supplementary materials) indicated that girls reported more negative and less positive affect in interactions with fathers than boys. These findings highlight the need to assess family dynamics of mothers, fathers, and adolescents together, as well as taking into account sex of adolescents.

As our study provides first insights into the momentary experiences of families with DEP adolescents by monitoring parent-adolescent interactions and includes not only adolescents’ perceptions of parenting of mothers and fathers separately but also parents’ own perception, findings are relevant for clinical practice. Since DEP adolescents do seem to benefit from parental warmth in daily life, interventions on adolescent depression may benefit from the involvement of parents, both mothers and fathers. A recent meta-analysis has shown that the involvement of parents in treatment of adolescent depression can increase the efficacy of individual CBT [ 56 ]. These family interventions could include psychoeducation to inform parents about how depression and how cognitive biases can influence adolescents’ experiences of daily life, and foster a warm family climate, limiting parental rejection, and criticism. Moreover, given the substantial variation in how parenting and adolescent affect is related and previous findings that perceptions of adolescents and parents differ [ 57 , 58 ], exploring the needs of the adolescent in treatment and discussing them with parents also seems an important ingredient. This could yield more understanding of each other’s perception and behavior as well as aligning what adolescents need or want and what parents can provide.

Some limitations should be acknowledged that may provide directions for future studies. Our sample was fairly homogenous, with the majority of adolescents and parents being born in the Netherlands. Furthermore, our sample of families with a DEP adolescent might be biased. Families who decided to participate in the study, focusing on parent-adolescent interactions, may not be families with harsh or neglecting parenting behavior, thereby resulting in an underestimation of negative parent-adolescent interactions among families with DEP adolescents. Also, even though common comorbid disorders, such as anxiety disorders, were allowed, we excluded DEP adolescents with forms of comorbid psychopathology, such as autism, that may directly influence parent-adolescent interactions. As a result, findings may deviate from naturalistic patterns in adolescents which limits interpretation and generalizability. Although future studies may strive to include a more diverse, representative sample of DEP adolescents, it is also important to mention that the inclusion of comorbid disorders may pose challenges when it comes to elucidating the specific associations with adolescent depression and parent-adolescent interactions. Moreover, although we were able to assess experiences of parent-adolescent interactions in their natural context by using EMA, it may also have resulted in collecting data of interactions about mundane matters (e.g., who is unloading the dishwasher) that may not have a large impact on adolescents’ affect. Future studies may benefit from gaining additional information about the content of the interactions. Lastly, due to limited power we have to be cautious in interpreting the findings concerning interactions with fathers. We were also not able to test the direction of effects, but focused on concurrent associations during momentary parent-adolescent interactions. Future work assessing the direction of effects could result in more specific implications for clinical practice.

Parenting has been consistently associated with adolescent depression, but most research to date has used retrospective questionnaires concerning macro-time intervals. With the use of EMA and inclusion of families with a DEP adolescent, we showed that DEP adolescents overall reported more negative and less positive affect than HCs. Generally, perceived parental warmth and criticism and affect during parent-adolescent interactions co-fluctuated. This association did not differ between DEP adolescents and HCs, even though DEP adolescents and their parents did indicate more negative parenting (e.g., less care and more overprotection) in the retrospective questionnaires. These findings indicate that adolescents generally do seem to benefit from parental warmth, while the discrepant findings also support the idea that a negativity bias may have affected the retrospective reports of parenting. Clinicians should facilitate the communication of needs and perspectives between adolescents and parents. The study further supports the idea that the extent to which parenting processes relate to adolescent affect differs per family and therefore calls for a more person-centered and idiographic approach in research to guide family interventions.

Data availability

The de-identified data, analysis scripts, and materials for this study will be made available on DataverseNL.

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Acknowledgements

We highly appreciate the effort and time devoted by participating families. Furthermore, we thank the mental health organizations that contributed to the recruitment of participants as well as students who helped recruitment and data collection.

The study was supported by a personal research grant awarded to Bernet Elzinga from the Netherlands Organization for Scientific Research (NWO-VICI; Unravelling the Impact of Emotional Maltreatment on the Developing Brain 453-15-006).

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Loes H.C. Janssen, Bart Verkuil, Lisanne A.E.M. van Houtum, Mirjam C.M. Wever, Wilma G.M. Wentholt & Bernet M. Elzinga

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L.J. participated in the design, coordination and data collection of the study, performed statistical analyses, and drafted the paper; B.V. participated in the design and coordination of the study, helped interpreting the data and writing the paper; L.v.H. participated in the design, coordination and data collection of the study; M.W. participated in the design, coordination and data collection of the study; W.W. participated in the coordination and data collection of the study; B.E. (principal investigator) secured funding, conceived the study, participated in the design and coordination of the study, helped interpreting the data and writing the paper. All authors read, reveiwed, and approved the final paper.

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Janssen, L.H., Verkuil, B., van Houtum, L.A. et al. A closer look into the affect dynamics of adolescents with depression and the interactions with their parents: An ecological momentary assessment study. Eur Child Adolesc Psychiatry (2024). https://doi.org/10.1007/s00787-024-02447-1

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DOI : https://doi.org/10.1007/s00787-024-02447-1

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