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Depression in Children and Teens with Cancer

What Is Depression?

Depression, sometimes known as clinical depression, major depression, or major depressive disorder, is one of the most common mental health disorders. A depressive disorder can develop at any age. Among children and teens, depression is more likely after puberty. Symptoms of depression include feeling sad, down, or hopeless, and loss of interest in hobbies or activities.

Occasional symptoms of depression are common for someone facing serious illness like pediatric cancer. However, in a depressive disorder, symptoms are more severe, longer lasting, and affect daily function. Clinical depression is a real illness, and patients need specialized treatment such as psychotherapy or antidepressant medicine.

Despite the stress of pediatric cancer, most patients do not develop clinical depression. But support for mental health can help all patients and families cope with negative thoughts and emotions. A mental health professional can help families understand symptoms of depression, know when symptoms indicate a more serious disorder, and find resources to meet patient and family needs.

Signs and Symptoms of Depression in Children and Teens

Occasional thoughts or feelings of sadness or low mood are normal during the cancer journey. However, some patients may have more severe and longer lasting symptoms of depression that affect the way they feel, think, and act. Symptoms can vary, especially in children and teens. In a depressive disorder, symptoms are persistent and cause distress or problems in daily function.

Signs and symptoms of depression in children and teens may include:

  • Feeling down, low, sad, depressed, or irritable much of the time
  • Loss of interest or pleasure in hobbies or activities
  • Being easily bothered, annoyed, or frustrated
  • Feelings of worthlessness, hopelessness, or guilt
  • Withdrawal from friends and family
  • Problems sleeping
  • Trouble thinking or concentrating, not able to make decisions
  • Restlessness, not able to be still or slowing of speech or movements
  • Loss of appetite or change in eating habits
  • Crying more than usual
  • Fatigue
  • Thoughts of death or suicide

Depression may look different in children and adolescents compared to adults. For example, children and adolescents may be more irritable, angry, anxious, or defiant. They may also express more physical complaints or engage in risky behaviors.

Symptoms of depression can occur at any stage of the cancer journey. Sometimes, depression can be confused with symptoms that occur due to physical illness or as a side effect of cancer treatments or medicines. An accurate diagnosis is important to determine the best approach to treatment. If a patient shows symptoms of depression, families may be referred to a mental health specialist for further evaluation. Psychologists, psychiatrists, social workers, counselors, and other mental health providers have special training to diagnose and treat mood disorders and other mental health concerns.

Families may be surprised when a health care provider asks a patient about thoughts of suicide or past suicide attempts. However, suicide screening is becoming more common in medical settings. Suicide is the 2nd leading cause of death among young people ages 10-24. Screening for suicide can help at-risk youth get appropriate mental health care. Parents may be asked to step out of the room while the care team member asks about suicide risk. This may help the patient feel more comfortable and answer honestly.

Assessing suicide risk can be more challenging in children and teens facing cancer. Cancer patients face fears of dying and loss of friends. They might wonder if their families would be better off without them. These thoughts and questions about death can be normal in the pediatric cancer journey. However, a child or teen who expresses ongoing thoughts of death or comments about suicide should be seen by a mental health professional for a risk assessment. A mental health risk assessment provides more information on thoughts, feelings, behaviors, and plans to determine what mental health services may be needed.

It is important to remember that asking about suicide does not make a suicide attempt more likely. It does not put thoughts or ideas into someone’s head. Asking the question “Are you thinking about killing yourself?” can help save a life.

If you or someone you know may be considering suicide, call 911 immediately or contact the 24-hour National Suicide Prevention Lifeline any time at 1-800-273-TALK (8255).

Read about Suicide Prevention from the National Institute of Mental Health.

5 Action Steps for Helping Someone in Emotional Pain.

Risk of Depression in Children and Teens with Cancer

A serious illness, such as cancer, is a risk factor for depression. This means that pediatric cancer patients are at higher risk for depression compared to healthy peers. Having one or more risk factors does not mean that someone will develop depression. However, knowing risk factors can help families be more watchful and take steps to support mental health.

Risk factors that may contribute to depression in children and teens include:

  • Chronic illness
  • Previous depressive episode
  • Family history of depression or other mental illness
  • Family stress or conflict
  • Stressful life events or situations
  • Trauma or stress during early childhood such as abuse, neglect, or significant loss
  • Problems with school or peers
  • Bullying or social isolation
  • Traumatic brain injury
  • Poor coping skills or lack of support resources
  • Other mental health disorders such as substance use, anxiety, ADHD, or learning disabilities

A variety of other factors can affect mental health during the cancer journey. Treatments and procedures, pain, side effects, medicines, hormone changes, poor nutrition, sleep problems, and life disruptions can make it hard to cope. Patients may also struggle with accepting a “new normal” as they deal with long-term issues like physical limitations, body image, identity, ability to function at school or work, fertility, relationships, independence, and survival. In some patients, these factors may contribute to the development of depression.

Grief can be a risk factor for depression. During the cancer journey, many childhood cancer patients have to cope with losing a friend to cancer. For some children, this might be the first time to experience the loss of a loved one. This can also bring up negative thoughts and emotions about their own survival. However, having some symptoms of depression during bereavement does not mean a person has a depressive disorder. Each person has a unique experience of grief, so there is no true “normal.” But, there are some general differences between grief and depression.

  • During grief, a person usually experiences ups and downs of thoughts and emotions. In depression, mood tends to stay negative most of the time.
  • During grief, a person is less likely to have low self-esteem or feelings of worthlessness. In depression, self-criticism and low self-worth is common.
  • During grief, a person may wish to be reunited with a loved one in death, but these thoughts are different from thoughts or plans of suicide or wishing to die.

Understanding the differences between grief and depression can help match support resources to patient and family needs.

Types of Depressive Disorders in Children and Teens

A mental health professional uses specific guidelines to evaluate and diagnose mental health problems. During cancer, the diagnosis can be even more complex due to the effects of illness and treatments. Some of the more common disorders related to childhood depression include:

  1. In an adjustment disorder, a person experiences noticeable distress and mood changes in response to a significant life event or stressor. Emotional and behavioral changes may be out of proportion to what would be expected and often cause problems in daily function. There are subtypes of adjustment disorder including with depressed mood, anxiety, or mixed depressed mood and anxiety.

  2. In major depressive disorder, a person has persistent symptoms of depression for at least 2 weeks. Symptoms must include either depressed or irritable mood or loss of pleasure or interest in activities. Other symptoms of major depressive disorder include change in appetite or weight, sleep problems, fatigue, feelings of guilt or worthlessness, trouble thinking or concentrating, restlessness or slow speech or movements, and thoughts of death or suicide.

  3. A person with dysthymia has ongoing depressed or irritable mood that persists for at least one year. Other symptoms include change in appetite, sleep problems, fatigue, trouble thinking or concentrating, low self-esteem, and hopelessness.

    Dysthymic Disorder Among Children (NIMH)

  4. Disruptive Mood Dysregulation Disorder (DMDD) is a childhood mood disorder involving severe and persistent angry or irritable mood. Children have recurrent temper outbursts, occurring at least 3 times a week on average. Symptoms must be present for at least one year and be seen in different settings.

    Disruptive Mood Dysregulation Disorder (NIMH)

  5. In bipolar disorder, formerly called manic depression, a person has episodes of elevated mood (mania) that alternates with periods of depression. Symptoms of manic episodes in children and teens may include unusual silliness, irritability, increased activity levels, being more talkative, racing thoughts and ideas, decreased need for sleep, and changes in risk-taking or pleasure-seeking behaviors such as unusual sexual activity, shopping, or substance use. Because symptoms often overlap with other more common childhood conditions such as ADHD, DMDD, or anxiety, bipolar disorder is not a common diagnosis in children.

    Bipolar Disorder in Children and Teens (NIMH)

Managing symptoms of depression is important, whether or not a patient has a diagnosable disorder. Symptoms of depression can:

  • Contribute to health problems and physical symptoms
  • Interfere with cancer-related care and medical outcomes
  • Affect personal relationships
  • Make it hard to function at school or work
  • Impact nutrition, sleep, physical activity, and other health behaviors
  • Increase risk for other problems such as alcohol or substance use, smoking, or self-harm
  • Increase risk for suicide

A depressive disorder can also occur along with other common mental health problems such as anxiety disorders, substance use disorders, and attention deficit hyperactivity disorder (ADHD).

Identifying and treating depression in children and adolescents in a pediatric oncology setting is critical. Depression can not only have a negative impact on a child or teen’s overall well-being and quality of life, but unmanaged depression can also affect a child’s medical care and outcome, such as problems with adherence  to treatment or symptom management.

Dr. Kristin Canavera, Pediatric Psychologist

Treatment of Depression in Children and Teens

Psychotherapy and antidepressant medicines are often first treatments for a depressive disorder. Each person responds differently to antidepressant therapy, and it may take some time for depression to improve.

During cancer, mental health care can be even more complex in the context of the many stressors and challenges that patients and families face. A multidisciplinary care team is important to make sure that patients receive appropriate treatment for depression in the context of cancer care and other medical needs.

Providers who offer mental health services for depression include:

  • Psychiatrists
  • Psychologists
  • Mental health nurses
  • Clinical social workers
  • Counselors
  • Pastoral counselors
 

Psychotherapy for Depression

Psychotherapy, or “talk therapy”, is a main treatment for depression. One of the most effective types of psychotherapy for depression is Cognitive Behavioral Therapy (CBT). CBT helps patients identify negative thoughts and behaviors and to react to situations in a more helpful way. Psychotherapy may also focus on developing skills to solve problems, improve relationships, or manage stress. Specific coping strategies such as relaxation or mindfulness techniques, art therapy, music therapy, and play therapy may be helpful for children and teens with depression. Psychotherapy can occur in a variety of settings including individual, group, or family therapy.

Antidepressant Medicines

A doctor may prescribe medicine for depression. Antidepressants work over time to treat a depressive disorder. These medicines act on neurotransmitters thought to be involved in depression. Some patients may need a combination of medicines for full benefit.

Medicines used to treat depression in children and teens may include:

  • Fluoxetine (Prozac®)
  • Sertraline (Zoloft®)
  • Citalopram (Celexa®)
  • Escitalopram (Lexapro®)
  • Venlafaxine (Effexor®)
  • Duloxetine (Cymbalta®)
  • Bupropion (Wellbutrin®)

Patients taking antidepressants need regular doctor visits to make sure the medicines are working properly and to monitor any side effects. In rare cases, some medicines may prompt aggressive behavior or increase risk of suicide.

It is important to follow dosing instructions carefully. Patients should not take more than prescribed and should not stop taking the medicine without medical supervision. Be sure to let a doctor know if depression does not improve.

Questions to ask your doctor when prescribed an antidepressant medicine:

  • When should symptoms of depression begin to improve?
  • Are there any medicines or supplements that I should not take while taking this medicine?
  • What are the common side effects?
  • What side effects should I be particularly concerned about?
  • What should I do if I miss a dose?
  • How long will I need this medicine?

Specific cancer types and treatments may change the way the body responds to medications. It is possible that this may require using only certain antidepressant medications or even using less commonly prescribed medications for depression. Be sure to keep your full care team updated on any changes to your treatment plan or medications. Also, feel free to ask why a specific medication is being chosen if you have questions or concerns.

Medicines used to treat depression can be unsafe if taken more often or in greater amounts than prescribed or if stopped too quickly. Please ask your doctor before making any dose changes. Also, be sure to store medicines safely, and keep out of the reach of children.

Children and teens with depression should be monitored for suicide risk and worsening of symptoms. Patients often need ongoing therapy to prevent relapse of depression.

Coping with Symptoms of Depression: Tips for Parents and Caregivers

  • Help children and teens talk about thoughts and emotions. Be supportive and listen. Children and teens experiencing depression may internalize their feelings or avoid these discussions. Create a safe space for honest conversation. In addition to talking about feelings, find ways to help your child express thoughts and emotions in a way that has personal meaning. Journaling, art, music, and photography can be creative outlets for self-expression. Keep in mind that each person will have different communication styles and preferences.
  • Encourage social support. Having a strong social support can help protect against depression. Help children and teens stay connected to friends and family, and find ways to encourage meaningful relationships. Support groups may also offer an opportunity for new relationships with people who understand the cancer journey.
  • Encourage participation in activities and interests. Encourage your child or teen to get involved with hobbies, extracurricular activities, sports, or other activities of interest. Being involved in various activities can help improve mood, decrease social isolation, improve self-esteem, and provide additional opportunities for social support.
  • Identify triggers. The challenges of the cancer journey can be overwhelming. Each struggle or setback, no matter how big or small, can be another hit to mental health. Each person reacts to stressful events differently. Help your child identify triggers that cause negative thoughts or emotions. Be understanding when your child shares with you -- what is “no big deal” to you might be very upsetting to your child.
  • Use a variety of resources and strategies to help manage symptoms of depression. Depression can happen to anyone at any time. However, developing coping skills, strategies, and resources can protect mental health and promote well-being.
  • Encourage healthy behaviors, including exercise, healthy eating, and good sleep habits. Physical activity has been shown to reduce symptoms of depression, even in people with clinical depression. Eating a healthy diet and getting enough sleep are also important for mental health. Set small goals, and choose physical activities and healthy foods your child enjoys. Try to keep a regular sleep schedule, and limit distractions during rest time.
  • Seek help for your child (or yourself) if depression symptoms get worse. Mental health often takes a back seat to medical needs during cancer. However, depression can have a negative impact on health and medical outcomes. Depression is a real illness. Asking for help is not a sign of weakness. Talk to your care team or mental health provider. Seek help right away if you suspect there is risk of suicide.

Depression in Childhood Cancer Survivors

The rate of depression in childhood cancer survivors is about twice as high as in the general population. The reasons for the increased risk is not fully known. However, many survivors face lifelong challenges such as:

  • Brain changes due to treatments directed at the brain and central nervous system (CNS)
  • Ongoing health problems and late effects
  • Problems in school, work, or independent living
  • Family or relationship issues
  • Financial concerns

A comprehensive survivorship care plan that includes mental health follow-up and support is important for long-term wellbeing and quality of life after cancer.

Childhood cancer survivors can take steps to promote mental health:

  • Have good sleep habits.
  • Exercise regularly.
  • Eat a healthy diet.
  • Build a support network.
  • Have regular health check-ups.
  • Be aware of mental health, and seek help if needed.
 

Resources for More Information About Depression in Children and Teens


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Reviewed: April 2019