Metabolic syndrome defined and discover why people with schizophrenia and bipolar disorder are at highest risk for developing metabolic syndrome and diabetes.

Metabolic syndrome is a very important concept for everyone in the psychiatric community to understand. One reason is that metabolic syndrome is the current hot topic in mental health management and everyone is talking about it; hopefully, this includes your healthcare professionals. In fact, it's not possible to talk about diabetes and mental health without mentioning metabolic syndrome as they are intricately connected.

What is Metabolic Syndrome?

Metabolic Syndrome is a group of risk factors present in a single individual that promote the development of coronary artery disease, stroke, and type 2 diabetes. The symptoms of metabolic syndrome include:

• unhealthy cholesterol levels
• high blood pressure
• high blood sugar
• excess belly fat (waist circumference over 35" for women and 40" for men)

Those with metabolic syndrome are at risk of serious health problems including heart attack, stroke, and diabetes. In fact, the chance for diabetes can be as much as five times higher than in the general public. A person is said to have metabolic syndrome when elevations of the above measurements are present along with the increased waist size. Thus, it's the combination of the four criteria that leads to the most risk.

There are two direct connections between psychiatric disorders and metabolic syndrome:

1. poor diet and exercise regimen
2. high-risk antipsychotic medication use - especially with Clorazil and Zyprexa

Years of research show that psychiatric disorders are associated with heavy smoking, reduced income, lack of exercise, poor diet in terms of nutrition, obesity, and medications that cause weight gain. It's a perfect storm for metabolic syndrome ("Can You Prevent Diabetes and Metabolic Syndrome?").

Which Mental Illnesses Are Associated with Metabolic Syndrome and Diabetes?

Due to  treatment with certain high-risk antipsychotic medications, those with schizophrenia are at the highest risk of developing the risk factors associated with metabolic syndrome, closely followed by those with bipolar disorder. One of the key reasons is because some antipsychotic medications can raise blood sugars and cholesterol to dangerous levels and produce significant weight gain (referred to as "antipsychotic-induced weight gain"). It's important to note that without the weight gain and antipsychotic use factors, there does not seem to be a connection between metabolic syndrome and psychiatric disorders in general.

Even having one of the risk factors of metabolic syndrome, such as high blood sugar, isn't healthy, but when a person has combined risk factors such as high blood sugar and high cholesterol, this is a set up for very serious health problems- especially when a person has the added burden of a psychiatric disorder. When you experience the risk factors associated with metabolic syndrome, it doubles your risk of blood vessel and heart disease, which can lead to heart attacks and strokes. And as mentioned above, you also increase your risk of diabetes by five times.

Lesbian, gay, bisexual, transgender, questioning/queer, intersex, asexual, etc. (LGBTQIA+) youth have special concerns in terms of mental health. LGBTQIA+ parenting, gay bullying, anti-gay stigma, suicidal thoughts and actions, and LGBTQIA+ addiction are just some of these concerns. While there have been great gains in the acceptance of LGBTQIA+ people, there is still a long way to go for many and this lack of acceptance affects LGBTQIA+ youth and adults.

LGBTQIA+ Parenting

Some parents are very surprised to find out they are raising an LGBTQIA+ youth and some parents handle this better than others. Parents often feel a loss when an LGBTQIA+ youth comes out and admits to their sexuality because they see things like the weddings and grandchildren they wanted pass them by. And while in many places gay people can marry and adopt, the societal stigma against LGBTQIA+ people still reinforces the idea that they won't, shouldn't or can't.

Other LGBTQIA+ parenting challenges include the stigma faced by both parent and youth. Many parents fear telling others that they have a gay child as they are worried about the judgment of others and the notion that the parent "did something wrong" if their child is gay. LGBTQIA+ parenting also requires coming to terms with the fact that the LGBTQIA+ youth will likely experience stigma and discrimination themselves (When LGBTQIA+ Discrimination, Stigma Affects Your Mental Health) and the parents can do very little about it. It can be painful for parents to watch their children go through these struggles.¹

Gay Bullying

Gay bullying is one component of anti-gay stigma and is often one thing that parents of LGBTQIA+ youth worry about. The worry of gay bullying is not without merit. In studies:²

• 22% of LGBTQIA+ youth have reported that they don't feel safe at school
• 90% of LGBTQIA+ youth have reported being harassed or assaulted during the past year
• 25% of LGBTQIA+ youth reported missing school in the past 30 days due to fear
• 33% of LGB youth reported being threatened by a weapon at school
• 35% of LGB youth reported a suicide attempt in the last 12 months

And study after study also shows that those who experience verbal, physical or sexual assault are at greater risk for mental illnesses such as depression, anxiety or post-traumatic stress disorder.

LGBTQIA+ and Addiction

LGBTQIA+ youth have a much higher rate of substance use than do their heterosexual peers. In a study published in 2008, when compared to heterosexual youth:³

• The odds of substance use in LGB youth were 190% higher
• The odds of substance use in bisexual youth were 340% higher
• The odds of substance use in lesbian youth were 400% higher

It is thought that the problems of stigma in society are what lead to this increased risk. Says Michael P. Marshal, Ph.D., assistant professor of psychiatry at the Western Psychiatric Institute and Clinic of UPMC:

"Homophobia, discrimination and victimization are largely what are responsible for these substance use disparities in young gay people. History shows that when marginalized groups are oppressed and do not have equal opportunities and equal rights, they suffer. Our results show that gay youth are clearly no exception."

LGBTQIA+ Youth Support

These challenges do not have to be faced alone, however. There are many LGBT youth groups that provide access to help and LGBTQIA+ youth support.

For families, PFLAG – Family and Friends of Lesbians and Gays – is an international organization with many local chapters that provides education, programs, support and advocacy. LGBT parenting is a major focus for this group.

Other LGBT youth organizations include:

• Gay, Lesbian and Straight Education Network (GLSEN)
• Rainbow Youth Hotline: 1-877-LGBT-YTH (1-877-542-8984)
• Trevor Suicide Prevention Line: 1-800-850-8078
• Youth Talkline: 1-800-96YOUTH

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The term "gay" may be confusing and even foreign to some, forcing people to ask, "What is gay?" or "Am I Gay?" And while some might think the definition of "gay" is simple, to many, it actually isn't. While "gay" can be thought of as a synonym to "homosexual," there is more to the meaning of gay than that.

Definition of Gay

Homosexuality is considered to be same-sex sexual attraction and behavior and "gay" is a synonym of homosexuality. The term "homosexuality"¹ was first used by Victorian scientists who considered same-sex sexual attraction and behavior a "moral deficiency."²

Homosexuality is still the correct term clinically, but even though homosexuality is no longer considered immoral, some people feel there are still negative overtones to the word given its origin. The term "gay" was initially a slang term developed to overcome some of these negative associations. It may have come from a nineteenth century French slang word, "gaie."

What is Gay?

Gay is a term that is not gender specific so men or women can be termed "gay." When identifying people as gay though, it's important to consider three things. According to Avert.org, an international charity, these things are:

• Sexual attraction
• Sexual behavior
• Sexual identity

For example, a person may feel same-sex sexual attraction but not identify as "gay" whereas another person who behaves sexually towards men and women may identify as "gay." Moreover, it is not uncommon for people to identify as "gay" at some times in their lives, while straight (not gay) at other times.

In other words, correctly identifying someone as "gay" is as often a personal choice as much as it is a textbook definition. Overall, it's the self-identification of being "gay" that is the most accurate.

article references

• What is Coming Out, and Should I Come Out of the Closet?
• Stages of Coming Out After Accepting Your Sexuality
• Teenagers Coming Out LGBTQIA+ – The Four Stages
• Coming Out To Parents LGBTQIA+
• Coming Out at Work? Consider These Things
• Top 4 Ways You Shouldn't Come Out LGBTQIA+
• Possible Consequences and Reactions to Coming Out
• How to Talk About Being Gay

Teenagers Coming Out: Stage 1 – Feelings

When teenagers are coming out, most feel like they are "different" from other kids. When looking back, most homosexual teens realize that they have felt different as early as five years of age. A boy might have played games more generally reserved for women, and vice-versa for girls. Patterns of social isolation from peers will usually begin here.

Teenagers Coming Out: Stage 2 – Doubts

Puberty is generally when kids begin to think that they might be gay because of their attraction to members of the same sex. Often teens bury these feelings.

"Young gay people often go through a stage where they label themselves bisexual as a way to give themselves more options," says Dr. Donna Futterman, Professor of Clinical Pediatrics at the Albert Einstein College of Medicine and the Director of the Adolescent AIDS Program, Children's Hospital at Montefiore, Bronx, New York.

It is not common for homosexual adolescents to come out during this period of identity confusion.

Then again, they may instead resort to isolating themselves for fear of being exposed. A lonely way of life can come about especially if their community does not have an active gay youth subculture.

Teenagers Coming Out: Stage 3 – Self-Acceptance

Studies show that most homosexuals did not fully accept their sexuality until their late teens or at some point in their twenties. This could be due to the social prejudice and discrimination (stigma) against homosexuality. If this social pressure is minimized, teenagers may find coming out easier.

Teenagers Coming Out: Stage 4 – Disclosure

In one study conducted online, of almost two thousand gays and bisexuals age twenty-five and under, the average age to reveal homosexuality was sixteen. Homosexual teens tend to not fully begin dating until out of high school, living alone or living in a city with a large gay population.

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Treatment for anxiety and depression is crucial. Depression and anxiety are two disorders that can debilitate an individual. However, when these disorders occur together, they tend to be worse than when either occurs alone.

Often, depression and anxiety are treated with the same techniques. Anxiety and depression treatment include medications, lifestyle changes, and therapy. Treatment for anxiety and depression is most successful if multiple techniques are combined.

Medication Treatment for Anxiety and Depression

The medications most often used to treat anxiety are a class of drugs known as benzodiazepines (also called "minor tranquilizers"). These include:

• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Clonazepam (Klonopin).

The main problem with these anxiety and depression medications is their potential for tolerance, physical dependence, and the likely recurrence of panic and anxiety symptoms when the medication is stopped. Hence, they are best used for treating short-term anxiety and panic.

It is essential to treat depression and anxiety together. When the depression is healed, symptoms of anxiety often diminish. For some people, the herb Kava provides relief from anxiety without the problem of addiction.

Exercise and Relaxation to Treat Anxiety and Depression

Because anxiety clearly has a physical component (especially when it manifests as a panic attack), techniques for relaxing the body are an important part of the treatment plan. Anxiety and depression treatment includes abdominal breathing, progressive muscle relaxation (relaxing the body's muscle groups) and biofeedback.

Regular exercise also has a direct impact on several physiological conditions that underlie anxiety and depression. Exercise reduces skeletal muscle tension, metabolizes excess adrenaline and thyroxin in the bloodstream (chemicals which keep one in a state of arousal) and discharges pent-up frustration and anger.

Cognitive-Behavioral Treatment of Depression and Anxiety

Cognitive-behavioral therapy (CBT) is a psychotherapy that helps alter anxious and depressive self-talk and mistaken beliefs that give the body anxiety-producing messages. For example, saying to yourself, "What if I have an anxiety attack when I'm driving home?" will make it more likely that an attack will ensue.

Overcoming negative self-talk is used to treat anxiety and depression. It involves creating positive counterstatements such as "I can feel anxious and still drive," or "I can handle it." What often underlies our negative self-talk is a set of negative beliefs about ourselves and the world. Examples of such mistaken beliefs are:

• I am powerless
• Life is dangerous
• It's not okay to show my feelings

Replacing these beliefs with empowering truths can help to heal the roots of anxiety and depression.(See the chart on cognitive distortions at the end of this section.)

Monitoring Diet to Treat Depression and Anxiety

Nutrition and diet can be monitored to aid in the treatment of anxiety and depression. Stimulants such as caffeine and nicotine can aggravate anxiety and leave one more prone to anxiety and panic attacks. Other dietary factors such as sugar, certain food additives and food sensitivities can make some people feel anxious.

Seeing a nutritionally oriented physician or therapist may help you to identify and eliminate possible offending substances from your diet. He or she can also help you to research supplements and herbs (e.g., GABA, kava, B vitamins, chamomile and valerian teas) that are known to calm the nervous system.

If you are suffering from a serious anxiety or depressive disorder, you may want to locate a clinic in your area that specializes in the treatment of anxiety and depression. Your local hospital or mental health clinic can give you a referral. In addition, you may wish to call (800) 64-PANIC to receive helpful material from the National Institute of Mental Health.

"If you're facing terror every day, it's gonna bring Hannibal to his knees" - Jim Ballenger, a leading expert on anxiety

While depression is often considered a low energy state and anxiety is considered a high energy state, anxiety and depression are more related than people think. Inside, a depressed person often experiences a lot of anxiety – even leading to panic attacks.

Of course, having panic attacks can itself be a depressing thing. Any lack of control within our lives can contribute to depression.

The Link Between Anxiety and Depression Disorder

Anxiety and depression disorders are not the same although there are similar elements. Depression generates emotions such as hopelessness, despair, and anger. Energy levels are usually very low, and depressed people often feel overwhelmed by the day-to-day tasks and personal relationships so essential to life.

A person with anxiety disorder, however, experiences fear, panic or anxiety in situations where most people would not feel anxious or threatened. The sufferer may experience sudden panic or anxiety attacks without any recognized trigger and often lives with constant nagging worry or anxiousness. Without treatment, anxiety and depression disorders can restrict a person's ability to work, maintain relationships, or even leave the house.

Both anxiety and depression treatment are similar, which may explain why the two disorders are so often confused. Antidepressant medication is often used for anxiety and depression and behavioral therapy frequently helps people overcome both conditions.

Why Are Depression and Anxiety Linked?

No one knows exactly why depression and anxiety often occur together. In one study, 85% of those with major depression were also diagnosed with generalized anxiety disorder and 35% had symptoms of panic disorder. Other anxiety disorders include obsessive-compulsive disorder and post-traumatic stress disorder (PTSD). Because they so often go hand in hand, anxiety, and depression are considered the fraternal twins of mood disorders.

Believed to be caused in part by a malfunction of brain chemistry, generalized anxiety is not the normal apprehension one feels before taking a test or awaiting the outcome of a biopsy. A person with an anxiety disorder suffers from what President Franklin Roosevelt called "fear itself." For a reason that is only partially known, the brain's fight-or-flight mechanism becomes activated, even when no real threat exists. Being chronically anxious is like being stalked by an imaginary tiger. The feeling of being in danger never goes away.

"Even more than the depression, it was my anxiety and agitation that became the defining symptoms of my illness. Like epileptic seizures, a series of frenzied anxiety attacks would descend upon me without warning. My body was possessed by a chaotic, demonic force which led to my shaking, pacing and violently hitting myself across the chest or in the head. This self-flagellation seemed to provide a physical outlet for my invisible torment, as if I were letting steam out of a pressure cooker." ~ Douglas Bloch, M.A., author of "Healing From Depression"

When Anxiety and Depression Occur Together

Being both anxious and depressed is a tremendous challenge. Clinicians have observed when anxiety occurs comorbidly (together) with depression, the symptoms of both depression and anxiety are more severe compared to when each disorder occurs alone. Moreover, the symptoms of depression take longer to resolve, making the illness more chronic and more resistant to treatment (read more about Depression Treatment).

Finally, depression exacerbated by anxiety has a much higher suicide rate than depression alone. In one study, 92% of depressed patients who had attempted suicide were also plagued by severe anxiety.¹ Like alcohol and barbiturates, depression and anxiety are a deadly combination when taken together.

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Major depression, aka clinical depression, is a serious mental illness. The first and most critical decision the therapist or doctor must make is whether to hospitalize a patient for treatment of major depression. Clear indications for inpatient major depressive disorder treatment are:

• Risk of suicide or homicide
• Grossly reduced ability to care for self in areas of food, shelter, and clothing
• The need for medical diagnostic procedures

A patient with mild to moderate depression can receive depression treatment in the therapist's or doctor's office. The patient's support system (family members, relatives, close friends) should be strengthened and involved in depression treatment whenever possible.

Antidepressants for Treatment of Major Depression

Studies have shown antidepressant treatment for major depression can dramatically reduce suicide and hospitalization rates. Unfortunately, very few suicide victims receive antidepressants in adequate doses, and - even worse - most receive no clinical depression treatment whatsoever.

One of the biggest problems with antidepressant treatment is most patients don't stay on their antidepressant medication long enough for it to be effective. A recent study found only 25% of patients started on antidepressants by their family physician stayed on it longer than one month. Antidepressant treatment of major depressive disorder usually takes 2-4 weeks before any significant improvement appears (and 2-6 months before maximum improvement appears).

First Line Antidepressants in the Treatment of Clinical Depression

The selective serotonin reuptake inhibitors (SSRIs) are typically tried first in major depression treatment and include:

• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)

These medications are considered excellent choices as the patient's first antidepressant because of their low incidence of side-effects (especially weight gain) and their low risk of causing death if taken in an overdose.

Because many patients with major depression also suffer with intense anxiety, lorazepam (Ativan) or other medications may be prescribed to reduce anxiety in mixed anxiety-depression treatment.

If this is the first major depressive episode, once a person positively responds to an antidepressant, this depression treatment should be continued for 4-9 months, according to the most recent (2008) American College of Physicians guidelines.² For those who have experienced two or more depressive episodes, longer treatment may be required.

Withdrawal from antidepressant treatment for depression should be gradual. Never discontinue taking medication without telling your doctor first. Suddenly stopping antidepressant medication could produce severe antidepressant withdrawal symptoms and unwanted psychological effects, including a return of major depression (read about antidepressant discontinuation syndrome).

Keep in mind, prescribing the right antidepressant in clinical depression treatment is challenging. It may take some experimentation on the part of the doctor to find the right antidepressant and dosage for you. Do not give up if everything doesn't come together right away. For cases where multiple medications haven't worked or the depression is severe, a psychiatrist should be consulted as they are experts in prescribing psychiatric medication.

Psychotherapy for Treatment of Major Depression

In general, psychiatrists agree severely depressed patients do best with a combination of antidepressant medications and psychotherapy. Medications treat the symptoms of depression relatively quickly, while psychotherapy can help the patient deal with the illness and ease some of the potential stresses that can trigger or exacerbate the illness.

Psychodynamic Therapy

Psychotherapy treatment of depression is based on the premise human behavior is determined by one's past experience (particularly in childhood), genetic endowment and current life events. It recognizes the significant effects of emotions, unconscious conflicts and drives on human behavior.

Interpersonal Therapy

The National Institute of Mental Health (NIMH) studied interpersonal therapy as one of the most promising types of psychotherapy in major depression treatment. Interpersonal therapy is a short-term psychotherapy, normally consisting of 12-16 weekly sessions. It was developed specifically for the treatment of major depression and focuses on correcting current social dysfunction. Unlike psychoanalytic psychotherapy, it does not address unconscious phenomena, such as defense mechanisms or internal conflicts. Instead, interpersonal therapy focuses primarily on the "here-and-now" factors that directly interfere with social relationships.

There is some evidence in controlled studies that interpersonal therapy as a single agent is effective in reducing symptoms in acutely depressed patients of mild to moderate severity.

Behavior Therapy

Behavior therapy involves activity scheduling, self-control therapy, social skills training and problem solving. Behavior therapy has been reported to be effective in the acute treatment of patients with mild to moderate depression, especially when combined with antidepressant medication.

Cognitive Behavior Therapy (CBT)

The cognitive approach to psychotherapy maintains irrational beliefs and distorted attitudes toward one's self, their environment and the future perpetuates symptoms of depression. CBT depression treatment attempts to reverse these beliefs and attitudes. There is some evidence cognitive therapy reduces depressive symptoms during the acute phase of less severe forms of depression.

Electroconvulsive Therapy (ECT) in Major Depressive Disorder Treatment

Electroconvulsive therapy (ECT) is primarily used for severely depressed patients who have not responded to antidepressant medicines and for those who have psychotic features, acute suicidality or who refuse to eat. ECT, as a major depression treatment, can also be used for patients who are severely depressed and have other chronic general medical illnesses which make taking psychiatric medications difficult. Changes in the way ECT is delivered have made ECT a better-tolerated treatment for major depression.

Importance of Continuation of Major Depression Treatment

There is a period of time following the relief of symptoms during which discontinuation of the major depressive disorder treatment would likely result in relapse. The NIMH Depression Collaboration Research Program found four months of clinical depression treatment with medication or cognitive behavioral and interpersonal psychotherapy is insufficient for most depressed patients to fully recover and enjoy lasting remission. Their 18-month follow-up after a course of depression treatment found relapses of between 33% - 50% of those who initially responded to a short-term treatment.

The current available data on continuation of clinical depression treatment indicates patients treated for a first episode of uncomplicated depression who exhibit a satisfactory response to an antidepressant should continue to receive a full therapeutic dose of that medication for at least 6-12 months after achieving full remission. The first eight weeks after symptom resolution is a period of particularly high vulnerability to relapse. Patients with recurrent depression, dysthymia or other complicating features may require a more extended course of depression treatment.

In a 1998 article, in the Harvard Review of Psychiatry, entitled "Discontinuing Antidepressant Treatment in Major Depression," the authors concluded:

"The benefits of long-term antidepressant treatment in major depression and the risks of discontinuing medication at various times after clinical recovery from acute depression are not as well defined. Computerized searching found 27 studies with data on depression risk over time including a total of 3037 depressive patients treated for 5.78 (0-48) months and then followed for 16.6 (5-66) months with antidepressants continued or discontinued. Compared with patients whose antidepressants were discontinued, those with continued treatment showed much lower relapse rates (1.85 vs. 6.24%/month), longer time to 50% relapse (48.0 vs. 14.2 months), and lower 12-month relapse risk (19.5 vs. 44.8%) (all p < 0.001). However, longer prior treatment did not yield lower post-discontinuation relapse risk, and differences in relapses off versus on antidepressants fell markedly with longer follow-up. Contrary to prediction, gradual discontinuation (dose-tapering or use of long-acting agents) did not yield lower relapse rates. Relapse risk was not associated with diagnostic criteria. More previous illness (particularly three or more prior episodes or a chronic course) was strongly associated with higher relapse risk after discontinuation of antidepressants but had no effect on response to continued treatment; patients with infrequent prior illness showed only minor relapse differences between drug and placebo treatment."

Treating Refractory Depression

Refractory depression, aka treatment-resistant depression, occurs in as many as 10% - 30% of depressive episodes, affecting nearly a million patients. Katherine A. Phillips, M.D. (1992 winner of a NARSAD Young Investigator Award) has found failure to provide adequate doses of medication for sufficient periods of time is perhaps the most common cause of apparent depression treatment resistance. Once the clinician has determined a patient is truly treatment-refractory, many treatment approaches can be tried. Phillips recommends the following refractory depression treatment strategies:

1. Augmentation with lithium and perhaps other agents like a thyroid medication. Trazodone (Oleptro) may be worth trying either alone or in combination with fluoxetine (Prozac) or a tricyclic antidepressant if other approaches have failed.
2. Combining antidepressants - supplementing the SSRI antidepressant with a tricyclic antidepressant. Several studies have shown a good response when fluoxetine (Prozac) is added to tricyclics and when tricyclics are added to fluoxetine. It is important to monitor tricyclic levels because fluoxetine can raise tricyclic levels by 4-11-fold and thereby cause tricyclic toxicity.
3. Switching antidepressants - stop the first SSRI antidepressant gradually and then substitute another SSRI antidepressant or SNRI antidepressant like venlafaxine (Effexor). Fluvoxamine (Luvox), sertraline (Zoloft) or venlafaxine (Effexor) often are effective for fluoxetine (Prozac) or paroxetine (Paxil) nonresponders (and vice versa).

Read more about depression treatment for hard-to-treat depression.

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Teenage depression is more common than once thought. Estimates show 4.7% of adolescents are experiencing depression at any given time. While depression in teenagers is very similar to that of adults, teens have particular challenges involving school, family, peer pressure and bullying that can make managing depression more difficult.

It can be difficult to tell if a teen's behavior is normal moodiness or signs of teenage depression. If a teen cannot deal with their emotions or if the symptoms persist and start to interfere with life-functioning, it's time to consider teenage depression as a possibility. (teenage depression test here)

Signs and Symptoms of Teenage Depression

Signs and symptoms of teenage depression are similar to that of adults (read: Depression Symptoms). The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) lists only one difference between teen and adult depression: teens may have an irritable mood rather than a depressed one. Other symptoms of teenage depression include:¹

• Diminishing ability to feel pleasure; disinterest in hobbies
• Sleeping and eating changes
• Agitation, restlessness, anger, irritation
• Slowed thinking, speaking and movements
• Fatigue, tiredness
• Feelings of worthlessness, guilt
• Trouble thinking, concentrating, remembering
• Frequent thoughts of death, dying or suicide
• Crying spells
• Unexplained physical pain
• Disruptive behavior; often seen in males
• Preoccupation with body image, performance; perfectionism; often seen in females

Depression in teenagers often occurs alongside other mental disorders like attention-deficit/hyperactivity disorder (ADHD), eating disorders or an anxiety disorder.

Teenagers and Antidepressants

Teenage depression is often treated by addressing the environmental and psychological factors of the depression. These issues may be handled by a school counselor or in therapy. However, in some cases, often with severe or reoccurring episodes of depression, antidepressants may be prescribed for teenagers.

The Food and Drug Administration (FDA) warns that antidepressants can increase suicidal thoughts and behaviors, particularly during initial treatment so an adult should always closely monitor any teenager's depression treatment. Adults may wish to ensure the medication schedule is followed exactly so the teen does not hoard medication in a later attempt to commit suicide.

Few antidepressants have been studied and approved for use in teenagers, but antidepressants are used based on approval, research data or their use in the adult population. All types of antidepressants can be used in teenagers but selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed first (see list of antidepressants). Antidepressants typically used in teenagers include:

• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Citalopram (Celexa)
• Escitalopram (Lexapro)

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Childhood depression can be a life-threatening illness and deciding on treatment for a child with depression can be daunting. While certain types of psychotherapy, like cognitive behavioral therapy, have been shown beneficial in childhood depression, sometimes antidepressant medication for children must also be considered. Therapy combined with antidepressants is thought to produce the best outcomes in children with depression. Medication treatment alone is typically insufficient.

Antidepressants for children may be considered when:¹

• Severe depression symptoms don't respond to therapy
• Therapy is not available
• The child has chronic or reoccurring depression
• There is a family history of good response to medication for depression
• There are no known substance abuse issues
• The child shows no signs of psychosis or bipolar disorder

Effects and Side Effects of Antidepressants on Children

Antidepressants in children treat depression and have shown some ability to protect against suicide. However, there is some concern about an increase in suicidal thoughts in some kids (see below). Doctors must carefully weigh the benefits vs. the risks of putting a child on antidepressants.

The side effects of antidepressants on children are difficult to predict due to the lack of good-quality research in the area. There are multiple types of antidepressants that may be used, but typical types of antidepressants for children include:²

• Selective serotonin reuptake inhibitor (SSRI) – side effects are dose dependent and may disappear with time. SSRI side effects in kids include: mania, hypomania, behavioral activation, gastrointestinal symptoms, restlessness, diaphoresis, headaches, akathisia, bruising, and changes in appetite, sleep and sexual functioning.
• Tricyclic (TCA) – carry higher risk for overdose; medical tests are required before treatment starts and monitoring of weight should be done while taking TCAs.

Antidepressants in children should be administered in tolerable and therapeutic doses for at least four weeks. If no improvement is seen at four weeks, a dose increase is warranted.

FDA Approval and Warning for Children on Antidepressants

"Children on antidepressants" is controversial in some circles, with the possible exception of children and fluoxetine (Prozac), which seems to have been deemed useful in most medical circles. In December of 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for the treatment of "depressive illness." The MHRA notes fluoxetine (Prozac) as an exception.

In October of 2003, the Food and Drug Administration (FDA) issued a public health advisory warning about suicidality in children treated with antidepressants. The FDA advised that children on antidepressants may experience suicidal thoughts and behaviors (suicide attempts).

There are few FDA-approved medications for depression in children. Antidepressants are often used due to their success in adults or due to studies in the pediatric population. Options for antidepressants in children typically include:

• Fluoxetine (Prozac) – FDA approved for depression treatment ages eight and up; has the most positive research behind it.³
• – FDA approved for treatment of obsessive compulsive disorder in ages seven and up; sometimes used to treat depression in children.⁴
• Fluvoxamine (Luvox) – FDA approved for treatment of obsessive compulsive disorder in ages eight and up; sometimes used to treat depression in children.⁵
• Imipramine (Tofranil) – FDA approved for treatment of enuresis (bedwetting) in children age six and up; sometimes used to treat depression in children.⁶
• Desipramine (Norpramin) – FDA approved for depression treatment in children ages 12 and up.⁷
• Amitriptyline (Elavil) – FDA approved for depression treatment in adolescents.⁸

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