- Antony Nguyen
Depression is common mental health disorder, which affects over 350 million people of all ages worldwide1. It is estimated that one in every six people in Australia are likely to experience a diagnosable depressive at some stage of their lives and occur more often in females than males2. In the years up to adolescence, depression is considerably more common and could be related to family problems, the birth of a sibling, or impacts on the child’s social ties (moving to a new house or school)3. Depression is frequently linked with other mental health illnesses, such as disruptive behaviour disorders, anxiety disorders and substance use disorders4. However, it depends on the illness and the severity of the individuals as they have a range of effective treatments such as specialist management, treatment with medication and/or erratic use of health care services that together can help people on the road to recovery. Emergency services often attend a spectrum of jobs from mental health problems to major trauma and/or even neonate to the elderly. Paramedics are called to those jobs where they must demonstrate the knowledge and treatment in suspecting depression and suicidal ideations in a child. Although there are efforts in the treatment of depression there is no one proven way that people recover from depression.
Depression has come to be widely recognised as a significant psychiatric illness of childhood and adolescence5. Depression is more than just feeling sad. Depression involves the equilibrium of naturally occurring chemicals in the brain, called neurotransmitters6. Neurotransmitters affects the mood of a person and drains the energy, motivation, and concentration a person needs for normal activities7. It also hinders with the ability to notice or appreciate the good things in life. However, it is normal to feel sad as a result of being hurt or losing something or someone of importance. People are affected by depression as they think and see negative side of themselves and the future8. When depression affects a person, the feeling of sadness becomes overwhelming and long- lasting thus affecting how a person thinks, feels and behaves. Along with feeling miserable, irritable and stressed it may seem nothing is meaningful. These feelings can last for weeks, months or even longer7. Depression involves the balance of naturally occurring chemicals in the brain. These chemicals, called neurotransmitters, affect mood. As it is a common mental health condition affecting everyone from time to time, children are often incompetent to explain how they are feeling, especially when depressed8.
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Depression is diverse for everyone, and there is no simple solution for why people develop the condition. For majority of people there are combinations of reasons. In children, depression varies from the everyday “blues” that most kids get as they mature. The fact that the common feeling such as sadness, loneliness or irritable does not mean the children has depression9. Childhood depression is persistently feeling sadness which is also affected by other factors for instance feeling hopeless, helpless and worthless 1, 2, 8, 9. Stressful life events may also be the trigger of depression for some children. Serious life events such as loss and grief, traumatic events, previous fluctuating mood, loneliness, bullying, disadvantaged socially, alcohol and drug use, environment, family problems, low self-esteem and body image and physical health problems are all influences of depression10. Childhood depression interferes with the child’s daily activities, coursework, and peer relationships. It may further progress to affect the lives of each family member. Health care professionals can diagnose and treat and manage childhood depression with medications and/or psychotherapy9. However, childhood depression is a severe depressive condition that can lead to suicide if left untreated.
Especially when children are depressed, they are often unable to elucidate how they are feeling8. It is clearly obvious when adults are depressed or feels sadness. Children with depression are difficult to engage and motivate as they tend to be in a constant low mood5. Depression in childhood may causes the child to cry and whinge and easily become irritable. Other factors including feelings of misery and guilt may result in outburst of anger. Children are more a risk of depression when they live with family members have also experienced depression7. Children can easily relate to how parents or carers who are depressed. It is possible that the stress affecting the child affects the entire family. Childhood is a valuable time for mental health as it is estimated that 75 per cent of adult mental health disorders emerge before the age of 25 11.
People affected by depression show signs and symptoms for example emotional, cognitive, behavioural and physical changes. Not everyone who is depressed expresses it in exactly the same way, though. Depression involves feelings of unhappiness, sadness, moodiness and irritability, and sometimes emptiness or numbness for weeks or more5, 9, 10. Some children feel guilty, excluded, or unloved3, 9. In conjunction of these emotions, they play a part of a depressed mood.
Children with depression have a tendency to have negative and self-critical thoughts 10. In addition, depression affects their decisions making skills and concentration. It may be difficult for the child to pay attention in the class, complete schoolwork, or stay focused on what others say12. As their state of mind is altered they may believe they are worthless and unlovable. The world for a depressed child would look bleak, as thoughts reflecting on hopelessness and helplessness which would make matters worse. Depression can causes someone to be more accident prone or to think that life is not worth living3. Furthermore, this could lead to serious consequences such as harming themselves or ending their own life7.
Behavioural changes can easily be noticed in children affected by depression. People with depression feel sadness and less motivated, this may cause the person to withdraw from close friends and family or from activities which they once relished3. Depression also alters people who feel tired, drained, or exhausted, thus actions or activities may take longer to do or as if everything required more effort. Poor attention to personal hygiene and appearance, avoidance of family interactions, substance abuse, psychomotor retardation, self-harm and more time spent along are key observations to determine that depression is affecting the behaviour of a person3, 13. This behaviour change makes them feel further secluded and isolated and can surge depression and negative thinking.
Not only does depression affect the mind, it also affects the body. Physical signs of depression include loss of appetite and weight, fatigue, restlessness and agitation, trouble sleeping, bed wetting, or hibernation, unexplained aches and pains3, 12, 13. Depression differs from person to person, but there are some mutual signs and symptoms. When these symptoms are overpowering and disabling, it is important to seek for help.
Depression is a major risk factor for suicide. Depression leads people to focus mostly on failures and disappointments, to emphasize the negative side of their situations10. The Australian Bureau of Statistics (ABS), most recent ‘cause of death’ indicates that in 2011, suicide was leading cause of death for young people aged 15 to 24 14. Although at some stage everyone feels sad, depressed, or angry at times in regards to dealing with burdens of school, friends and family. For other people they may feel that the sadness or hopelessness never goes away or things will never go right for them again and/or believe ‘there is no way out’ or ‘it never gets better’.
Serious warming signs of depression include the thoughts of death or suicide. The deep despair and fruitlessness that goes with depression can make suicide feel like it is the only option to escape the pain. Children may encounter extremely stressful events may be the trigger and warning signs of suicide include:
- feeling alone, isolated, alienated and withdrawing from friends and family
- experiencing traumatic life event, such as abuse, bullying or violence
- experiencing discrimination and isolation due to sexuality, culture or disability
- Being preoccupied with death in conversation, writing, or drawing
- giving away belongings
- making suicidal statements. 2, 10, 15
“It is not just a warning sign that a person is thinking about suicide: it’s a cry for help” 15. It is significant that all threats of suicide should seek professional help immediately.
Depression in a universal disorder but it can be unnoticed in children. As the symptoms of depression are simply overlooked by negative behaviours (e.g. whingeing), it is easy for adults to feel miffed by them or dismiss the child for his or her behaviour10. Hence the continuation of this can further lead to missing other clues of depression. Observing and identifying a child’s emotion will aid in detecting signs of depression earlier so that help can be intervened 6, 10. With this information the parent/guardian/teachers of the child should refer to a mental health assessment by the general practitioner or school counsellor/psychologist1-3, 8, 10, 13. No single test can determine whether a child has depression or is just feeling down. However, children and young people in Australia have access to a national 24 hour free telephone counselling service if required.
Suicide is a complicated phenomenon that is swayed by an extensive range of risk and protective factors16. Emergency services (ambulance, police and emergency departments) are the key to suicide prevention providers. As suicides are classified as life threatening situation it requires immediate intervention. Paramedics are often called to attend suicidal patients with a compassion and understanding of suicide and mental illness to provide an effective response.
Children in particular present with diverse behaviour and mood changes which may suggest they may be feeling depressed. A simple approach that should be demonstrated by all paramedics is to talk to the child. Even though the child may not be able to explain his/her feelings, discuss and explore the problems in a supportive manner and take the time to listen. When children are depressed their thinking gets congested by lots of negative ideas8, 16. It is important that the child knows it is perfectly fine to ask for help, as well as the paramedic being supportive as this starts to improve their mood. Be respectful of the child’ comfort level and resist any urge to criticize or pass judgement. Other factors that could assist children with depression are encouraging the children to keep active as it helps to restore physical health and wellbeing whilst improving children’s mental health and encouraging children to keep up with the normal routines and activities aids to divert them from negative thoughts8, 16. The normal process is to take all patients to the emergency department, using appropriate triage procedures, treatments and medication. However, children under the ages 12 years old should seek help from a mental health professional or referred to the general practitioner if the child’s behaviour or mood doesn’t in improve in a few weeks.
Suspected depression and suicidal ideation in a child should seek professional help immediately. In regards to legal reasoning of suicide, suicide itself is not a crime however – CRIMES ACT 1958 – SECT 6B – states that; incites any other person to commit suicide and that other person commits or attempts to commit suicide in consequence thereof; or aids or abets any other person in the commission of suicide or in an attempt to commit suicide — can be charged with manslaughter and second degree murder17. Ethically suicide poses a difficult question, however, the person who commits suicide intends to terminate life whereas the other who threatens suicides or unsuccessfully attempts at it intends to improve their life.
Depression is considered as a common condition that causes distress to the person, their family and friends. Since depression is a considerably a subjective anomaly, less severe depressive signs and symptoms may not come to the attention of parents/carers, whereas additional crucial symptoms might. Children in specific, with depression, need to be observed carefully as behaviour and mood consistently differ from adults. There is an extensive array of treatments, medication, management and mental health professional support when a person suffers from depression and other mental health problems at use. Although no one proven there is way that people recover from depression, never give up as we all feel ‘down’ or sad from time to time – it’s part of being human.
1.WHO. Depression. World Health Organization; 2012; Fact sheet N°369 [Available from: http://www.who.int/mediacentre/factsheets/fs369/en/.
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3.Institute BD. Depression. Black Dog Institute; 2014 [cited 2014 25 April]; Available from: http://www.blackdoginstitute.org.au/public/depression/inchildren.cfm.
4.Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J, Dahl RE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry. 1996;35(11):1427-39. Epub 1996/11/01.
5.Kent L, Vostanis P, Feehan C. Detection of Major and Minor Depression in Children and Adolescents: Evaluation of the Mood and Feelings Questionnaire. Journal of Child Psychology and Psychiatry. 1997;38(5):565-73.
8.KidsMatter. About depression. 2013; Available from: http://www.kidsmatter.edu.au/families/mental-health-difficulties/depression/depression-how-depression-affects-children.
9.WebMD. Childhood Depression. 2014 [cited 2014 25 April]; Available from: http://www.webmd.com/depression/childhood-depression.
10.Beyondblue. Depression. 2014; Available from: http://www.youthbeyondblue.com/understand-what%27s-going-on/depression.
11.Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry. 2005;62(6):593-602. Epub 2005/06/09.
12.TeensHealth. Depression. 2014 [cited 2014 25 April]; Available from: http://kidshealth.org/teen/your_mind/mental_health/depression.html#.
13.headspace. Depression. 2014 [cited 2015 25 April]; Available from: http://www.headspace.org.au/what-works/research-information/depression#3B.
15.Melinda Smith MA, Joanna Saisan MSW, Jeanne Segal PD. Depression Symptoms & Warning Signs 2014. Available from: http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.htm.
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