Depression in Adolescents PREMA MANJUNATH, MD CHILD AND ADOLESCENT PSYCHIATRIST

Depression in Adolescents PREMA MANJUNATH, MD CHILD AND ADOLESCENT PSYCHIATRIST

Francis Bacon Children sweeten labors, but they make misfortunes bitter. They increase the cares of life, but they mitigate the remembrance of death

William Wordsworth 1802 My heart leaps up when I behold A rainbow in the sky; So it was when my life began; So it is now I am a man; So be it when I shall grow old, Or let me die! The Child is father of the Man; I could wish my days to be Bound each to each by natural piety.

Meaning of the Seventh Line Profound meaning Man is the product of his habits and behavior In his childhood and adolescence

Definition Depressive disorders are Recurrent, Familial Illnesses associated with Significant Morbidity/Mortality

Why is Adolescent Depression Important Early identification (Primary Care Setting) and Effective treatment Reduces the impact of depression on the adolescent s Normal growth and Psychosocial Functioning Reduces the risk for Suicide (Mood Disorders account for majority of adolescent suicides and are the Third leading cause of death in Adolescence Reduces the risk for Substance Abuse

Why is Screening for /Recognition of Depression Important Often Unrecognized Stigma attached Parents are not aware Signs may be missed as typical teenage behaviors Teens may hide disorder actively Only 25-33% of depressed youth receiving treatment (Burns et al 1995, Leaf 1996)

Adolescence, A Vulnerable Stage Depression often first presents during Adolescence Developing Brain Sleep Disturbances Hormonal Changes Substance Abuse Psychosocial Pressures

Sad Consequences Subsequent mood episodes, mania (20-40%) Academic underachievement/failure Peer and family relationship problems Suicide attempts, completed suicide, accidental deaths Long term educational and social difficulties Substance Abuse, antisocial behavior, high risk behavior

Epidemiology Point prevalence 4-8% in Adolescence Incidence increases with age By age 18, 20% of teens have had a depressive episode Male: Female ratio is 1:1 Childhood, 1:2 Adolescence

Symptoms Withdrawal from social activities Irritability Self- Criticism Low self-esteem Frequent somatic symptoms Tearfulness and crying

Symptoms Distinct and enduring mood and behavioral change School problems/academic Underachievement Family conflicts Illicit substance use and abuse Suicidal Crises Aggressive behaviors

Terminology

Diagnostic Terms DSM-5 American Psychiatric Association 2013 Major Depressive Disorder MDD Dysthymic Disorder in DSM IV is now Persistent Depressive Disorder Persistent Depressive Disorder can include both Chronic Depression and Major Depression Double Depression is no longer used. New disorder Disruptive Mood Dysregulation Disorder DMDD

Diagnostic Criteria Formal diagnosis of MDD was conceptualized for Adults MDD is defined by DSM-5 as follows: Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1. depressed mood or 2. loss of interest or pleasure Next Slide

DSM- 5 Criteria for Depression Depressed mood: In children and Adolescents, this can present as irritable mood Diminished interest or pleasure in all or almost all, activities Appetite and weight changes Sleep pattern disruption Psychomotor agitation or retardation Fatigue of loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to concentrate, indecisiveness Recurrent thoughts of death, recurrent suicidal ideations without a specific plan, or a suicide attempt or a specific plan for committing suicide

DSM 5 Depression Criteria for diagnosing depression for children and adolescents similar to adults accept Irritability can be primary mood symptom instead of sadness in individuals under the age of 18 Failure to meet normal expected growth milestones can be submitted for the weight loss criteria.

DSM -5 Additional Criteria Symptoms cause significant distress, impairment in social, occupational functioning Symptoms are not due to the direct physiological effects of a substance(drug of abuse, medication) or general medical condition (i.e. Hypothyroidism) Symptoms not better accounted for by bereavement ( if symptoms persist > than 2 months after loss of a loved one)

DSM- 5 Disruptive Mood Dysregulation Disorder New Disorder Characterized by frequent, severe, recurrent temper outbursts Chronically irritable and or angry mood Both of these must be present for at least one year Cannot be accounted for by other mood disorders Included in the DSM-5 to reduce the misdiagnosis of bipolar disorder in children with chronic irritability DMDD shares many characteristics of Oppositional Defiant Disorder without the oppositionality High degree of overlap between symptoms of ODD and Depression raises the question as to whether DMDD really is a distinct disorder More Research needed

Spectrum of Depression Major Depressive Disorder, Single Episode Major Depressive Disorder, Recurrent Dysthymic Disorder/ Persistent Depressive Disorder Adjustment Disorder with Depressed Mood Depression Not Otherwise Specified Bipolar Disorder Substance Induced Mood Disorder

Subtypes of Depression Catatonic Depression Psychotic Depression Unipolar Depression Bipolar Depression Melancholic Depression Pre-menstrual Dysphoric Disorder Seasonal Depression

Etiology

Etiology - Biologic Correlates Genetics Neuroendocrine HPA axis Neurotransmitters Sleep Abnormalities Brain Anatomy Dysfunction

Etiology Psychological Correlates Dysfunctional attitudes Affect Regulation Problems Sexual identity Issues Negative life events (loss, failure) Abuse Co-morbid psychiatric Disorders

Etiology Social Correlates Parental Depression

Comorbidity Anxiety Disorders Post Traumatic Stress Disorder Conduct Problems ADHD OCD Learning Difficulties

Suicidal Behaviors Suicidal thoughts: 1/6 girls, 1/10 boys 100:1 ratio of attempts to completions 60% of depressed youth have thoughts of suicide 30% of depressed youth make a suicide attempt Risk factors: family history, previous attempts, comorbidities, aggression, impulsivity, access to lethal means, negative life events

Primary Care as a Place for Action Extensive literature in adult primary care about identification and treatment Integrated models show improved outcomes Improved identification without other changes have little or no effect on outcome April 2009: US Preventive Services Task Force endorsed depression screening in Pediatric Primary Care for teens 12-18 Screening is useful only if systems in place to ensure accurate diagnosis, therapy and follow up

Action in Pediatrics/ Adolescent Medicine How is depression identified in the office setting? Patient Interview/ Complaints Parental Interview/ Complaints Screening Tools

Patient Interview HEADSS Interview includes depression and suicidality questions Issues: Do Physicians have time for a full interview? Are they trained to ask these questions in a productive way? Will adolescents be forthcoming? Should questions be asked at all visits or only at scheduled health maintenance visits?

Parental Interview Pros: With Adolescents parental awareness of depression in their teens will increase access to mental health services. Cons: Few parents are aware of their adolescent s symptoms (Logan and King, 2002), and often Adolescents may arrive without their parents.

Rating Scales CES- DC : Center for Epidemiologic Studies- Depression Scale MFQ: Mood and Feelings Questionnaire DSRS : Depression Self- Rating Scale KADS: Kutcher Adolescent Depression Scale PHQ-A: Patient Health Questionnaires Adolescent Beck Depression Inventory SDQ: Strengths and Difficulties Questionnaire

Screening Instruments : Cons : Time consuming to screen all Burden on the system Many Instruments are available- how do you choose (PHQ-A or Beck s? False Positives possible Improved outcomes depend on proper follow up of the positive screens

Screening Instruments: Pros: Increased identification is possible Universal screening is possible, recommended by some Time efficient in the waiting room May increase adolescent disclosure of symptoms

Confidentiality Issues in Depression and Suicide Screening Legality of breaking confidentiality varies by state Confidentiality must be broken when a teen is a danger to self or others Clinician needs to judge when parental involvement is beneficial or harmful

The Diagnostic Process Best if Collateral information is collected from many sources (school, parent, etc.) Positive Screens/ questions should be followed up: Suicidality must be addressed Safety issues- may need to send teen to the Emergency Room

The Diagnostic Process Co-morbidity is the rule, not the exception Depression frequently occurs with anxiety disorders, ADHD, oppositional defiant disorder, conduct disorder and substance abuse, etc. Must rule out Bipolar Disorder

Clinical Course and Outcome Recurring, spontaneously remitting Average episode: 7-9 months 40% probability of recurrence in 2 years 60% likelihood in adulthood Predictors of recurrence: poorer response, greater severity, chronicity, previous episodes, comorbidity, hopelessness, negative cognitive style, family problems, low SES, abuse or family conflict

Treatment Aims Reduce symptoms and impairment Shorten episode Prevent recurrences

Principles of Management For All cases Conduct a Risk Assessment Admission? Establish Severity: Clinical Assessment+ Rating Scales Supportive Management: Rapport, Education, Support, Psychotherapy, Problem Solving, Stress Management, Sleep Hygiene, Exercise, Healthy lifestyle

Treatment Options Depending on the severity Watchful waiting Supportive management Psychosocial Interventions CBT Cognitive Behavior Therapy IPT Interpersonal Psychotherapy Medication

Treatment What Works? Robust evidence of effectiveness for: Medication (moderate and severe depression) Psychotherapy (milder depression) CBT IPT

Treatment CBT Identify links between mood, thoughts, activities Challenge negative thoughts Increase enjoyable activities Build skills to maintain relationships

Treatment IPT Similar to CBT Focus on the Present Premise- Interpersonal Conflicts-Loss of Social Support-Depression Improvement of Interpersonal Skills Psychoeducation about depression Increase enjoyable activities

Treatment Medication Strong placebo effect Evidence different for adults Informed consent Under treatment common Most Evidence for SSRIs Fluoxetine: approved > 8years Escitalopram: approved for adolescents in the US

Treatment Which Antidepressant? Effectiveness and safety Fluoxetine start with 10mg, increase to 20mg after one week 30-40mg for adolescents If not Fluoxetine try another SSRI (eg Escitalopram or Sertraline) Continue treatment 6 months after recovery

Treatment Adverse Effects of SSRIs Suicidality Manic Switch Akathisia/Agitation/ Irritability Disinhibition Nightmares/Sleep disturbances Gastrointestinal Weight gain Sexual side effects Withdrawal syndrome/serotonin syndrome

Treatment Other Treatments ECT severe cases Transcranial Magnetic Stimulation TMS Light Therapy in Seasonal Affective Disorders Complementary and Alternative Medicine (CAM) St.John s Wort Omega 3 fatty Acids S-Adenosyl Methionine (SAMe) Exercise

Treatment :Unipolar Depressions Severity Psychosis Second Generation or Atypical Antipsychotics

Treatment: Bipolar Depression Ist line: Lithium or quetiapine 2 nd line : Lithium or Valproate with an SSRI, olanzapine and an SSRI,or Lamotrigine Antidepressants alone not effective Lithium and valproate should be avoided in women of childbearing age

Refractory Depression/ treatment Resistance Determining Treatment Resistance Handling Treatment Resistance Possible causes Patient factors Family Factors Environmental Factors Clinician Factors

Barriers to Care Shortage of Child Psychiatrists and Allied Professionals Few Training Programs Stigma Few Medications Minimal Inpatient Facilities/Residential Treatment facilities

Summary Points Depressive disorders are familial recurrent illnesses associated with significant psychosocial morbidity and mortality Depressive disorder prevalence increases after puberty, affecting twice as many females as males Although most depressions remit, a substantial proportion of youth experience recurrences The etiology of depressive disorders seems to be determined by the interaction of certain genes with the environment and support systems and the youth s cognitive and coping style There are no biological tests that guide the diagnosis. The diagnosis is based on a comprehensive evaluation

Summary Points During all phases of treatment depressed youth and their parents should be offered education and support There is evidence that CBT, IPT and the SSRI antidepressants in particular Fluoxetine are efficacious. Combination of Therapy and antidepressants seems to be more efficacious for some youth Antidepressants may induce side effects and in predisposed individuals mania and about 1-3/100 youth treated with these medications may show onset or worsening of suicidal ideations and rarely suicide attempts Treatment during the acute phase should include antidepressants and psychotherapy

Summary Points After successful acute treatment all youth should be offered continuation treatment with SSRIs and or Psychotherapy Depressed youth who do not respond to monotherapy, either psychotherapy or an antidepressant require a combination of these two modalities Youth with severe depression or frequent recurrences should receive maintenance treatment with SSRIs and/or Psychotherapy for at least one year to prevent recurrence Management of Resistant Depression should take into account factors associated with poor response to treatment such as noncompliance, misdiagnoses, ongoing negative events and the presence of comorbid disorders. When one SSRI ineffective switching to another helpful. Adding Lithium or Bupropion may help.

Summary Points Treatment of Subtypes of Depression including Seasonal, Bipolar, or Psychotic Depression may require special treatments like light therapy, mood stabilizers and antipsychotics respectively. Management of Co-morbid disorders, ongoing conflicts and family psychopathology is necessary to achieve remission Studies are needed to evaluate whether DMDD is a distinct condition or simply a more extreme phenotype of Depression and or ODD or whether or whether it is a phenotype more ubiquitous among several psychiatric disorders Regardless management of irritability symptoms is crucial for the well being of the teen.

References / Further Information American Academy of Child and Adolescent Psychiatry (AACAP 2007) Practice parameter on Depressive Disorders http://www.jaacap.com/article/s0890-8567(09)62053-0/pdf National Institute for Health and Clinical Excellence (NICE) (2005) guideline http:www.nice.org.uk/guideline/cgguidelinereview

References Textbook of Child and Adolescent Psychiatry DSM-5 Edition, Mina K.Dulcan IACAPAP Textbook of Child and Adolescent Mental Health, editor Joseph Rey The Treatment for Adolescents with Depression Study (TADS): long-, term effectiveness and safety outcomes. March, Silva et al. Archives of General Psychiatry. 2007 Oct;64 (10): 1132-43 Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence review -73for the US Preventive Task Force. Williams et al. Pediatrics 2009; 123: 716-735 Fluoxetine,cognitive-behavior therapy, and their combination for adolescents with depression:treatment of Adolescents with Depression Study(TADS) JAMA Aug 182;292(7):807-20

A Light IN The Attic by Shel Silverstein There s a light on in the attic. Though the house is dark and shuttered, I can see a flickerin flutter, And I know what it s about. There s a light on in the attic. I can see it from the outside, And I know you re on the inside..looking out.

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