More Than Just Moody Blaise Aguirre, MD Child and Adolescent Psychiatrist McLean Hospital Assistant Professor of Psychiatry Harvard Medical School

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1 More Than Just Moody Blaise Aguirre, MD Child and Adolescent Psychiatrist McLean Hospital Assistant Professor of Psychiatry Harvard Medical School

2 Keep in Mind In the U.S., approximately 10-15% of children/adolescents show some signs of depression. Every year about 8% of teens will begin to show signs of depression. Adults are more likely to recognize their depression and be treated, while most teenagers will not receive the help they need. Common symptoms of depression in adolescents include irritability, withdrawal, isolation, loss of interest and/or pleasure in previously enjoyed activities, sleep problems, changes in appetite and reduced energy.

3 And More Physical symptoms can be a symptom of depression (especially chronic headaches or stomach aches). Most young people with depression suffer from academic decline. Some use street drugs and alcohol in an attempt to self-medicate. Conflict with authority may result from irritability. Symptoms of depression vary with the developmental stage of the child. Denial of symptoms, aggression, excessive crying, and physical symptoms may be more common among preadolescent children.

4 Epidemiology Found in: 2% children and 4%-8% adolescents. Male/female ratio: Children 1:1, adolescents 1:2. Cumulative incidence by age 18 years: 20% Since 1940, each successive generation has been at a higher risk for MDD. 50% of depressed adults had their first episode before age 20. Life events: stresses play a role in timing and onset.

5 Typical Development Rapid Physical Growth. Sexual Maturation. Secondary Sexual Characteristics. Motivational and Emotional Changes. Cognitive Development. Maturation of Judgment, Self-Regulation Skills. Brain Changes Linked to Each Component.

6 Puberty and Motivation/Emotion Strongest links to pubertal changes per-se are in the domains of romantic motivation, sexual interest, emotional intensity, sleep/arousal regulation, appetite, and mood disorders. A general increase in risk-taking, novelty-seeking, sensationseeking (reward-seeking). Intensification of many types of goal-directed behavior, including intense motivation for long term and abstract goals (particularly related to social-status).

7 Transition to Adulthood Requires: Appropriately inhibit or modify behaviors to avoid negative future consequences. Initiate, persist, and organize steps toward goals. Navigate complex social situations despite strong emotions. Skills in the self-regulation of mood and complex behavior to serve long-term goals. Involves neurobehavioral systems in PFC -- among the last regions of the brain to achieve full functional maturation.

8 Just What Are They Thinking? Argue for the sake of arguing = exercising their new reasoning capabilities. Can be exhilarating. Jump to conclusions. Build trust by being a good listener. Be self-centered. It takes time to learn to take others perspectives into account; it is a skill that can be learned. Constantly find fault in the adult s position. This can be quite a change to adjust to, particularly if you take it personally or if your child idealized you in the past. Be overly dramatic. Everything seems to be a big deal to teens. Emotions going unchecked.

9 The Tragedy of Youth Primary causes of death/disability are related to problems with control of behavior and emotion. Increasing rates of accidents, suicide, homicide, depression, alcohol and drug use, violence, reckless behaviors, eating disorders, health problems related to risky sexual behaviors Increase in risk-taking, sensation-seeking, and erratic (mood dependent) behavior.

10 The Ultimate Tragedy In 2007, suicide was the third leading cause of death for young people ages 15 to 24. As in the general population, young people were much more likely to use firearms, suffocation, and poisoning than other methods of suicide, overall. Nearly five times as many males as females ages 15 to 19 died by suicide. Girls think about and attempt suicide about twice as often as boys, and tend to attempt suicide by overdosing on drugs or cutting themselves. Boys are more likely to succeed as they use more lethal methods.

11 Diagnostic Criteria: DSM-IV At least 2 weeks of an enduring change in mood manifest by either depressed or irritable mood and/or loss of interest and pleasure. Other symptoms: changes in appetite, weight, sleep, activity, concentration or indecisiveness, energy, self-esteem (worthless, excessive guilt), motivation, recurrent suicidal ideation or acts. Symptoms represent change from prior functioning and produce impairment. Symptoms are not attributable to substance abuse, medications, other psychiatric illness, bereavement, medical illness.

12 Complexities in Diagnosing Depression: Overlap of mood disorder symptoms. Symptoms overlap with comorbid disorders. Developmental variations in symptom manifestations. Are disorders spectrum or categorical disorders. Effects of medical conditions.

13 Depression Symptoms in Youth Frequent sadness that won t go away, crying. Feeling hopeless, helpless, withdrawn. Change in behavior, loss of interest in usual activities. Change in sleep, appetite or energy. Missed school or poor school performance. Frequent physical complaints. Irritability, fighting, trouble concentrating. Thoughts about death, suicide or running away.

14 Other Factors and Consequences Associated with MDD Academic struggles can lead to low parental satisfaction with child. Personality traits: judgmental, anger, low self-esteem, dependency. Cognitive style and temperament: negative attributional styles. Early adverse experiences: parental divorce or loss of a parent. Conflictual family relations which can include neglect and abuse.

15 Causes of Depression in Youth Biological/Environmental/Psychological Genetics (family history) Neurochemical Life Stress Sleep Medical Substance Use Children with a depressed parent are 3x more likely to have lifetime episode of MDD. Prevalence of MDD in first-degree relative of children with MDD is 30%- 50% (parents of depressed children also have anxiety, substance abuse, personality disorders).

16 Depression in Adolescents The clinical picture may look similar to adult depression. Suicidal thoughts and behavior is a serious risk and must be addressed even in less severe presentations. Substance abuse, conduct disorder and school failure may also be complications.

17 In Younger Children More symptoms of anxiety (i.e. phobias, separation anxiety), somatic complaints, auditory hallucinations. Express irritability with temper tantrums and behavior problems, have fewer delusions and serious suicide attempts. Thoughts of death are often magical: I will come back after this is all over.

18 Low Self Esteem Feeling blue. Lacking energy. Disliking one s appearance and rejecting compliments. Feeling insecure or inadequate most of the time. Having unrealistic expectations of oneself. Having serious doubts about the future. Being excessively shy and rarely expressing one s own point of view. Conforming to what others want and assuming a submissive stance in most situations.

19 Clinical Variants of MDD: Need for Different Intervention Strategies Psychotic Depression. Bipolar Depression. Atypical Depression. Seasonal Affective Disorder. Subclinical or Subsyndromal Depression. Treatment-Resistant Depression.

20 What Else Might it Be? Anxiety disorders: such as separation anxiety, GAD. Disruptive and ADHD Disorders. Learning Disorders. Substance Abuse. Eating Disorders: Anorexia Nervosa. Personality Disorders. Premenstrual Dysphoric Disorder.

21 Consequences of Insufficient Sleep in Adolescents? Missed school. Sleepiness. Negative synergy with alcohol. Decreased motivation. Irritability and low-frustration tolerance. Difficulties with self, emotional, and behavioral control. Difficulties with focusing attention and concentration. Moodiness. Difficulty in integrating, consolidating and storing newly learned material. Directly affects accurate recall of facts.

22 Concerns about Treatment of MDD There is little research on treatment for MDD in children and adolescents. Varied opinions about whether psychotherapy or medications, or a combination should be the first-line treatment. Initial acute treatment depends on: severity of MDD symptoms, number of prior episodes, chronicity, age, contextual issues in family, school, social, negative life events, compliance, prior treatment response, motivation for treatment.

23 Treatment of MDD in Children & Adolescents Psychotherapy for mild to moderate depression. Empirically effective psychotherapies: CBT, ITP, DBT Antidepressants can be used for: bipolar depression, psychotic depression, depression with severe symptoms that prevents effective psychotherapy or that fails to respond to adequate psychotherapy. Due to psychosocial context, medications alone may not be effective

24 Treatment of MDD in Children & Adolescents Few studies of acute treatment with medication for MDD in this age group. Almost no pharmacokinetic and dose-range studies. SSRI s may induce mania, hypomania, behavioral activation (such as impulsivity, silliness, irritability and agitation). No long-term studies of the treatment of MDD. The long-term effects of medications are not yet known. We don t know the effects of medication on rapidly developing brains.

25 FDA Review of Studies for Antidepressant Drugs 20 placebo-controlled studies of 4100 pediatric patients for 8 antidepressant drugs (citalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, venlafaxine). Excess of suicidal ideation and suicide attempts when receiving certain antidepressant drugs; no suicides. FDA could not rule out an increased risk of suicidality for any of these medications. Data was adequate to establish effectiveness in MDD only for fluoxetine based on 2 studies.

26 Moodiness or Depression Every teen sulks at times. Daily moodiness is not depression. Take note of whether your teen s brooding is getting in the way of going to school, eating and sleeping, participating in sports or meeting up with friends. Is this his or her typical pattern? If so, the moodiness is most likely normative. Keep an eye on your child s classmates and friends. Birds of a feather! Take note if teen expresses a great deal of distress, begins to disengage or isolate or says she wants to disappear or talks about suicide.

27 Treating Moodiness Your child is not trying to torture you. He is doing the best he can So are you. Is struggling with hormones, emotional instability and social strife. Cut her a little slack. It s never OK for children to hurt others with their actions, no matter what they re going through. Explain how their actions affect you or other family members. Avoid you phrases. Use I phrases, like I felt hurt when you.. Recognize that your child might not respond positively in the moment. Adolescent moodiness generally only lasts a couple of hours!

28 Final Thoughts Adolescent depression is real. Comes at a time of multiple changes. Is distinguishable from adolescent moodiness.