DEPRESSION IN CHILDHOOD AND ADOLECENCE

Transcription

1 DEPRESSION IN CHILDHOOD AND ADOLECENCE Bob Salo

2 Mood Disorders Childhood Depression Major Depressive Disorder Disruptive Mood Dysregulation Disorder Bipolar Affective Disorder Mainly Depressive Mainly Hypomanic Mixed Mood Disorders complicating other psychiatric disorders

3 Depression PREVALENCE OF MAJOR DEPRESSION 2% of children 5-8% of adolescents Upto 15% of adolescents have mood disorders: (dysthymia, Depressive Disorder, Depressive adjustment disorder)

4 Depression Depressed mood, or irritable mood every day Diminished interest in play, work, activities which usually afford pleasure or interest, apathy Diminished ability to concentrate, indecisiveness, clinginess Weight loss or gain, or failure to grow because of diminished food intake. Insomnia or hypersomnia Agitation or retardation of activity levels Feelings of worthlessness, guilt or hopelessness Recurrent thoughts of death or dying, or recurrent suicidal thoughts.

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6 Depressive Disorders DSM5 Field Trials - Diagnostic Reliability Mixed Anxiety-depressive Disorder Colorado Unacceptable Stanford Unacceptable Pooled Unacceptable Major Depressive Disorder Colorado Questionable Stanford Questionable Pooled Questionable

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11 Depression Differences between Children and Adolescents Younger children unable accurately to describe their inner mental states Irritability common Somatic symptoms common Reduced weight gain rather than weight loss

12 Clinical Signs and Symptoms of Child vs Adolescent Depression Signs and Symptoms Child Adolescent Anhedonia Hopelessness Sleep Weight /- - Appearance Somatic Complaints Fears and Worries Suicide Ryan et al. (1987) and Rosenberg et al (1992, 1994)

13 Genetics and Depressive Disorders Twin studies: MZ : DZ = 4:1 Twin studies suggest that Genetic effect = 60% of variance Family studies Familial aggregation Heritability =30-40% Environmental influences important Depression is a complex disorder Consistency of findings

14 Depression: Risks Upto age 10: After age 10: Females = Males Females > Males More 1st and 2nd degree relatives have depression Risk of depression before 18: 1 Depressed Parent = 2x risk. 2 Depressed Parents = 4x risk Males whose fathers die, before the age of 13, are more likely to develop depression

15 Depression and Temperament Characteristic ways of interacting with the world which is moulded by both genetically transmitted traits and interactions with the environment that begin at birth or before and may influence the development of depression in the following ways Direct Indirect Mediate the role of factors such as stress Moderate the role of temperament (related to coping styles)

16 Depression and Temperament Vulnerability - temperament places the individual at risk of a disorder Pathoplastic - temperament shapes the course of the disorder Scarring - experience of a disorder changes personality and increases vulnerability Spectrum disorder is endpoint of a trait expression

17 Depression High Hormonal levels Cortisol, Dehydroepiandosterone Increase in rates of depression after puberty Rate increases more rapidly mid puberty Higher rates in females than males

18 Depression Environmental Stresses Attachment General Family functioning Conflict Losses and Life Events Adolescence Gender socialisation

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20 Depression Suicide: 3rd leading cause of death in adolescents Suicide and suicidal ideation frequent in depressed adolescents Males more at risk.

21 Individual Predisposition Alcohol abuse Depression Character Disorder -aggressive/impulsive -perfectionistic/rigid Proximate (Trigger) Stress Event Altered state of mind (hopelessness; fear/dread, rage etc) Opportunity: available method, privacy etc Social Milieu High or Low community rates Taboos Media Display Inhibit or facilitate SUICIDE Case finding and treatment Hotlines Firearm education Preventions Media Guidance Enhance Taboos

22 Age Specific Suicide Rates 2010 Males 13.4 per 100,000 Females 5.2 per 100,000

23 Age Specific Suicide Rates: 2010

24 Suicide rates by State/Territory Deaths Standardised death rate (per 100,000) State Males FemalesPersons New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory Australian Capital Territory Total 1, ,

25 Assessing Risk

26 4 Rs Recognising the signs Raising the issue Risk Assessment Responding

27 Establish Rapport Non Judgmental Unhurried Active listening Confidentiality issues Individual Assessment Family involvement Make some positive comments

28 Depression Self harm Substance abuse Recent Loss Recognising the signs: Antisocial Aggressive behaviour possession of a firearm. Antecedents

29 Numerous Accidents Recognising the signs: Behaviours Dangerous Risky Behaviours Morbid thoughts Giving away favoured possessions

30 Other Risk Factors Psychiatric disorders Poor social adjustment Physical health problems Family and Environmental Factors

31 Raising the issue Ask directly about suicidal, self harming thoughts Talk to the young person alone Do not swear secrecy

32 Factors that impede disclosure Clinician not prepared Anxiety / fear about mismanagement Anger with repeated self harmers Denial of possibility of suicide because of personal views

33 Depression >17% of adolescents with depression present with substance abuse Somatic complaints are common Behaviour problems, grouchiness, aggression are common Social withdrawal, school difficulties Neglect of personal hygiene Increased emotionality and sensitivity to feelings of rejection Depressive Delusions and Hallucinations uncommon (rare before puberty)

34 Assessing Suicide Risk : 1 1. Have you been feeling depressed for several days at a time? 2. When you feel this way, have you ever had thoughts of killing yourself? 3. When did these thoughts occur? 4. What did you think you might do to yourself? 5. Did you act on these thoughts in any way? 6. How often do these thoughts occur? 7. When was the last time you had these thoughts?

35 Assessing Suicide Risk : 2 8. Have your thoughts ever included harming someone else as well as yourself? 9. Recently, what specifically have you thought about doing to yourself? 10. Have you taken any steps towards doing this? (e.g., getting pills / buying a gun) 11. Have you thought about when and where you would do this? 12. Have you made any plans for your possessions or left any instructions for people for after your death, such as a note or a will?

36 Assessing Suicide Risk : Have you thought about the effect your death would have upon your family or friends? 14. What has stopped you from acting on your thoughts so far? 15. What are your thoughts about staying alive? 16. What help could make it easier for you to cope with your problems at the moment? 17. How does talking about all this make you feel?

37 Attempted Suicide Risk Factors Male gender Poor Communication History of Previous Attempts Depressive Symptoms Sense of Hopelessness Persistent Suicidal Ideation

38 Suicide and Attempted Suicide Psychopathology: psychiatric disorder common amongst suicides High rates of behaviour disorder High rates of Substance abuse especially amongst males Parent - Adolescent Communication less good in suicides

39 Attempted Suicide Suicidal ideation : 27% thought of suicide in the last 12 mths; (ages 14-17) Lethal Intent: 16% had made a plan; 8% had made an attempt; 2% an attempt which required medical attention 70% certainly survivable, 26% lethal potential 4% death a distinct possibility Females more likely to attempt suicide than males ( but less so as ascertained by community samples) Low SES associated with suicide attempts

40 F:M = 6:1 Attempted Suicide Usually only return for a few sessions therefore brief intervention strategies are important Cognitive problem solving strategies Identify potentially stressful situations Improve family communications and support, reduce conflictual situations

41 Attempted Suicide Attempters : low rates of affective disorders, high rates of Disruptive disorders, and substances abuse Cognitive Factors: Outcome: sense of hopelessness; poor problem solving strategies, negative attributional style, impulsive style 50% will repeat attempts within the first 2 yr... 10% (approx.)will complete suicide

42 DEVELOPING A MANAGEMENT PLAN 1. Establish a Therapeutic Alliance 2. Be systematic in your assessment 3. Where feasible, remove all obvious means of self harm. 4. Ensure appropriate supervision for the individual 5. Ensure immediate 24 hour access to suitable clinical care 6. Where feasible, neutralise the precipitating problem 7. Try to make a contract to keep themselves safe 8. Try to delay the individuals suicidal impulses: offer strategies 9. Identify supportive people or services who can be contacted 10. Engage in ongoing consultation with colleagues

43 Treatment Options

44 Treatment Options Empathic listening, monitoring. Psychotherapy: CBT, IPT, Psychodynamic, other psychotherapies Antidepressants Referral Education Liaison Coordination of ongoing care

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46 Evidence bases: Psychological Interventions INTERVENTION STRENGTH OF RECOMMENDATION QUALITY OF EVIDENCE COGNITVE BEHAVIOURAL THERAPY B+ INTERPERSONAL THERAPY B- FAMILY THERAPY B

47 Mild Depression Listen Are there any high risk factors Watch and Wait Review

48 Moderate Depression Assessment risk of self harm Assessment of protective factors Assessment of severity of depression and co-morbidities If low risk: Assess severity and risk Provide Client & Carer education Develop safety plan Develop treatment plan Inform about treatment options Inform about medication risks and side effects and benefits Establish a review and emergency procedure & educate what to look for. If psychological support initiated, if after 6-8 weeks no improvement consider adding antidepressant

49 Severe Depression Actively suicidal Psychotic features Requires immediate admission Consider CAT assessment if not willing to go to hospital with a view to involuntary admission

50 Referral Actively suicidal Depression Severe Psychotic Symptoms Bipolar disorder Worsening despite treatment No response to treatment after 2-3 weeks

51 Other Options CBT, IPT Psychotherapy etc Refining Antidepressant therapy Phototherapy Hospitalisation ECT

52 Treatments Unipolar: Bipolar:» Antidepressants» CBT» Antidepressants,» Mood Stabilisers,» CBT, Psychotherapy» ECT

53 Antidepressants SSRIs preferably because of lower cardiotoxicity esp. in overdose All SSRIs carry a Black Box warning at least weekly supervision required for the first six weeks Fluoxetine has the strongest evidence base Adverse effects are not uncommon Lack of response: increase dose Lack of response to increased dose change to another SSRI If medication effective then treatment should continue for at least 12 months

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56 Adverse Effects Increase in suicidality; actual suicide rates are reduced by antidepressants Agitation Nausea, gastric irritation. Weight gain Sedation Serotonergic Syndrome esp. in overdose

57 Response to Antidepressants 30-50% will respond to first antidepressant If there are residual symptoms then relapse is high Of those that do not respond to the first antidepressant about 30-50% will respond to a second antidepressant. After four trials of antidepressants only ⅔ will have responded Response rates can be increased by including psychotherapy CBT or IPT Psychotherapy reduces relapse rates

58 Disruptive Mood Dysregulation Disorder Diagnostic criteria The four criteria listed below should be met: Severe, recurrent, disproportionate temper outbursts On average, three or more times per week. Temper outbursts are inconsistent with developmental level. Between outbursts, mood is persistently irritable or angry, most of the day and nearly every day.

59 Disruptive Mood Dysregulation Disorder POSITIVE CONDITIONS Onset of symptoms must be before age 10 Symptoms must have been present for 12 or more months Symptoms must not be absent for three or more consecutive months Children must be between 6 and 18 years of age Symptoms should be present in at least two of three settings (home, school, social situations) and are severe in at least one setting NEGATIVE CONDITIONS Symptoms are not better explained by another mental disorder e.g. ODD, CD, ADHD. Symptoms are not the manifestation of a substance or medical condition Full symptom criteria for manic/hypomanic episode have not been met for more than one day Behaviours do not occur solely during an episode of major depressive disorder

60 Disruptive Mood Dysregulation Disorder DSM5 Field Trials : Site reliability of diagnosis Baystate Colorado Columbia Unacceptable Good Unacceptable Pooled Questionable