Adolescent DepressionAdolescent Depression

Prof. Hani Hamed Dessoki, M.D.Psychiatry

Prof. Psychiatry

Chairman of Psychiatry Department

Beni Suef University

Supervisor of Psychiatry Department

El-Fayoum University

APA member

Agenda

• Introduction & History• Scope of the problem• Etiology• Clinical Manifestation• Suicide• Management

Teen Depression

Question

Depression is a choice.

True or False

What is Depression?

-Depression is a medical illness

-Major depressive disorder is

(reoccurring periods of depression)

-It is not just the feeling of “ups” and “downs:

It is the most common mood disorder

Major depressive disorder is classified by the feeling of sadness and loss of interest in nearly all activities for at least 2 weeks

Severity of Problem ….

Untreated Depression can be taken as important cause of suicide in adolescentssuicide in adolescents, even adults

A Brief History of Depression in Children and A Brief History of Depression in Children and AdolescentsAdolescents

• Case reports on childhood depression date to the Case reports on childhood depression date to the early 17early 17thth centurycentury

• Melancholia in children was first reported in the Melancholia in children was first reported in the mid-19mid-19thth centurycentury

• In general, however, the existence of depression prior to In general, however, the existence of depression prior to 1960 was seriously doubted because it was felt that 1960 was seriously doubted because it was felt that childrenchildren’’s s immature superegoimmature superego would not permit the would not permit the development of depressiondevelopment of depression

• Research from Europe and NIMH funded American studies Research from Europe and NIMH funded American studies in the 1970in the 1970’’s increased the awareness & acceptance of s increased the awareness & acceptance of childhood depressionchildhood depression

Depression: Scope of the Problem

• Children: 1 year prevalence rate of 2%

• Adolescents: 1 year prevalence rate of 4% to 8%

• National Cormorbidity Survey: 6.1%, 15-24 years

• Lifetime prevalence (up to age 18) 15%-20%

• 65% of adolescents report some depressive symptoms

• 5% to 10% of youth with subsyndromal symptoms have considerable psychosocial impairment, high family loading for depression, and an increased risk for suicide and developing MDD (Fergusson et al., 2005)

Scope of the Problem

• Mean length of episodes: 7 to 9 months

• 6% to 10% become protracted

• Recurrence: 30 -50%

• Approximately 20% develop bipolar disorder

• Associated with significant:• comorbidity• functional impairment • risk for suicide• substance use

Increasing Prevalence of Depression in Adolescence

Depressive Disorders:• Adults: 15-20% rates; 2:1 female to male• Age 11: Incidence low; males > females• Age 13: Incidence rising; males = females• Age 15, 18, 21: Incidence rising; males <

females

Complexities in Diagnosing MDD in Children and Adolescents

• Overlap of mood disorder symptoms• Symptoms overlap with comorbid disorders• Developmental variations in symptom manifestations• Etiological variations of mood disorders involving gene-

environment interactions• Are disorders spectrum or categorical disorders• Effects of medical conditions

Need to Recognize Developmental Variations of MDD

CHILDREN:• More symptoms of anxiety (i.e.

phobias, separation anxiety), somatic complaints, auditory hallucinations

• Express irritability with temper tantrums & behavior problems, have fewer delusions and serious suicide attempts

ADOLESCENTS:• More sleep and appetite

disturbances, delusions, suicidal ideation & acts, impairment of functioning

• Compared to adults, more behavioral problems

Differential Diagnosis: Complexities of Diagnosing MDD

• Overlap of symptoms with nonaffective disorders (i.e., anxiety, learning, disruptive, personality, eating disorders):

• Overlapping symptoms include: poor self-esteem, demoralization, poor concentration, irritability, dysphoria, poor sleep, appetite problems, suicidal thoughts, being overwhelmed

Seeking Help

Many people feel ashamed or afraid to seek help, others make light of their symptoms leading

them to suffer in silence.

It’s important to remember that depression isn’t a character defect or something that you have

brought on yourself

Understanding Psychiatric Disorders

Genetics

Prenatal environment

Attachment

Temperament

Parenting

Exposures

Phenotype

SES

ComprehensiveTreatment

Causes of Depression in TeensCauses of Depression in Teens

StressStress LossLoss Major disappointmentMajor disappointment Chemical imbalanceChemical imbalance Genetic dispositionGenetic disposition Some medications (i.e. narcotics, steroids) may trigger Some medications (i.e. narcotics, steroids) may trigger

depressiondepression Traumatic events (violence, abuse, neglect)Traumatic events (violence, abuse, neglect) Social problemsSocial problems Unresolved family conflictUnresolved family conflict

http://www.bchealthguide.org/kbase/topic/major/ty4640/course.htm

Why are Adolescents So Vulnerable?

Neurobehavioral Development in Adolescents

Early AdolescencePuberty stimulates

changes in brain systems regulating arousal and appetite that influence

intensity of emotion and motivation

Late AdolescenceWith age and

experience comes maturation of frontal

lobes which facilitates regulatory competence

Middle Adolescence adolescent emotional and

behavioral problems 2nd to poor regulation skills--particularly when gap between pubertal arousal and consolidation of cognitive skills is

extended

Stress in students leading to depression

• Parental pressure to perform and to stand out among other children

• If not come up to expectations• Frustration• Physical stress• Aggression• Undesirable complexes

• Extreme sensitivity to rejection or failure• Low self-esteem and feelings of guilt• Frequent complaints of physical illnesses such as

headaches and stomachaches• Frequent absences from school or poor performance in

school• Threats or attempts to run away from home• Major changes in eating or sleeping patterns

(American Academy of Child and Adolescent Psychiatry, 8/98)

Symptoms of Major Depression:Symptoms of Major Depression:Adolescents with depression may display some of the following signsAdolescents with depression may display some of the following signs

• Sad, blue, irritable and/or complains that nothing is fun anymore

• Trouble sleeping, low energy, poor appetite and trouble concentrating

• Socially withdrawn or performs more poorly in school • Can be suicidal

National Institute of Mental Health, Treatment of Adolescent Depression Study (TADS)

Symptoms of Major Depression:Symptoms of Major Depression:Adolescents with depression may display some of the following signsAdolescents with depression may display some of the following signs

Adolescent Anxiety

• Excessive worries• Worries about school performance• Difficulty making friends• Isolative• Perfectionistic• Rigid thinking and behavior patterns• Phobias

ConsiderConsider…..…..

It was once thought that only adults developed depression and that children and teens could not.

Symptoms of depression in children and teens can be difficult to recognize.

Mood swings and other emotional changes caused by depression may be overlooked as unimportant or as a normal part of growing up.

Prolonged or severe depression can lead to problems making and keeping friends, difficulty in school, substance abuse, suicidal behaviour, and other problems that may carry into adulthood.

Government of British Columbia- B.C. Health Guide: Depression in Childhood and Adolescencehttp://www.bchealthguide.org/kbase/topic/major/ty4640/course.htm

Depression thinking can become part of a child’s developing personality, leaving long-term effects in place for the rest of the child’s life.

Future of depressed school-age children….

• School performance and learning • Lack of trust – can lead to Substance abuse• Disruptive behaviour• Violence and Aggression• Legal troubles and even suicide

 

Clinical Course: Relapse

• Relapse is an episode of MDD during period of remission

• Predictors of relapse: Natural course of MDD, Lack of compliance, Negative life events, Rapid decrease or discontinuation of therapy

• 40%-60% youth with MDD have relapse after successful acute therapy

• Indicates need for continuous treatment

Clinical Course: Recurrence

• Recurrence is emergence of MDD symptoms during period of recovery (asymptomatic period of more than 2 months)

• Clinical & nonclinical samples probability of recurrence 20%-60% in 1-2 years after remission, 70% after 5 years

Recurrence predictors:• Earlier age at onset• Increased number of prior

episodes • Severity of initial episode• Psychosis• Psychosocial stressors• Dysthymia & other comorbidity • Lack of compliance with

therapy

Clinical Course: Risk of Bipolar Disorder

• 20%-40% MDD youth develop bipolar disorder in 5 years of onset of MDD

• Predictors of Bipolar I Disorder Onset: • Early onset MDD • Psychomotor retardation• Psychosis• Family history of psychotic depression • Heavy familial loading for mood disorders• Pharmacologically induced hypomania

Suicidal Ideation among Adolescents(Hoberman and Garfinkel 1988)

In a study of 229 completed youth suicides:• 62% had made a suicidal statement • 45% had consumed alcohol within 12 hours of killing

themselves• 76% had shown a decline in academic performance in the

past year

Teen Suicide in the U.S.

• There are 25 suicide attempts for every completion for our country as a whole

• There are between 100-200 teen attempts before completing suicide

• Girls attempt more often (3:1)• Boys complete suicide more often (4:1)• Every year approximately 2,000 teens suicide

Journal of American Academy of Child and Adolescent Psychiatry, Practice Parameters, 2002

Although suicide is the 11th leading cause of death for the overall population, it is the 3rd leading cause of death for 15-24 year olds.

Risk Factors for SuicideRisk Factors for Suicide

Current suicidal thoughts Other mental health or disruptive disorders, such as conduct

disorder Impulsive or aggressive behaviours Feelings of hopelessness A history of past suicide attempts A family history of suicidal behaviour or mood disorders A history of being exposed to family violence or abuse Access to firearms or other potentially lethal means Social isolation/alienation

Government of British Columbia- B.C. Health Guide: Depression in Childhood and Adolescencehttp://www.bchealthguide.org/kbase/topic/major/ty4640/course.htm

Some common precipitants of suicidal behavior in teenagers include:

death of a family member or close friend (particularly if by suicide) loss of a romantic relationship or good friendship loss of a parent through divorce or separation loss of a pet, treasured object, job or opportunity fear of punishment physical, sexual or psychological abuse unwanted pregnancy poor grades fight or argument with family member or loved one belief one has harmed or brought harm to a family member or friend embarrassment or humiliation concerns about sexuality suicide of a friend

Treatment of MDD in Children & Adolescents

• Psychotherapy for mild to moderate MDD

• Empirical effective psychotherapies: CBT, ITP

• Antidepressants can be used for: non-rapid cycling bipolar disorder, psychotic depression, depression with severe symptoms that prevents effective psychotherapy or that fails to respond to adequate psychotherapy

• Due to psychosocial context, pharmacotherapy alone may not be effective

Treatment of MDD in Children & Adolescents

• Few studies of acute treatment with medication for MDD

• Few pharmacokinetic & dose-range studies

• SSRI’s may induce mania, hypomania, behavioral activation (impulsive, agitated)

• No long-term studies of treatment of MDD; long-term effects of SSRI’s not known

Treatment of MDD in Children and Adolescents

• Small number of case reports (King et al, 1991; Teicher et al., 1990) described association between SSRI’s treatment and increased suicidal tendencies, possibly linked to behavioral activation or akathisia

• Abrupt discontinuation with SSRI’s with shorter half-lives may induce withdrawal symptoms that mimic MDD

• SSRI’s inhibit metabolism of some medications metabolized by hepatic enzymes (P450 isoenzymes)

• SSRI’s interact with other serotonergic medications (MAOI’s) to induce serotonergic syndrome (agitation, confusion, hyperthermia)

How is Teenage Depression Treated?

Depression is commonly treated with therapy or with therapy and medication. A combination of approaches is usually most effective:

Cognitive-behavioral therapy focuses on the causes of the depression and helps change negative thought patterns.

Group therapy is often very helpful for teens, because it breaks down the feelings of isolation that many adolescents experience (sometimes it helps just to know that "I'm not the only one who feels this way").

Family therapy as an adjunct to individual therapy can address patterns of communication and ways the family can restructure itself to support each member, and can help the teenager feel like others share the responsibility for what happens in the family.

Physical exercisePhysical exercise is helpful in lifting depression, as it is helpful in lifting depression, as it causes the brain's chemistry to create more causes the brain's chemistry to create more endorphins and serotonin, which change mood. endorphins and serotonin, which change mood.

Creative expressionCreative expression through drama, art or music is often through drama, art or music is often a positive outlet for the strong emotions of a positive outlet for the strong emotions of adolescents. adolescents.

Volunteer workVolunteer work is sometimes helpful for adolescents. is sometimes helpful for adolescents. Helping someone else whose problems are greater Helping someone else whose problems are greater than one's own offers a perspective and also an than one's own offers a perspective and also an opportunity to be helpful, which can increase one's opportunity to be helpful, which can increase one's sense of purpose and meaning. sense of purpose and meaning.

MedicationMedication for depression should be used with great for depression should be used with great caution, and only under careful supervision. Recent caution, and only under careful supervision. Recent studies by both the UK government and the FDA have studies by both the UK government and the FDA have led to warnings that not all psychiatric drugs may be led to warnings that not all psychiatric drugs may be appropriate for teenagers and children. Seek a appropriate for teenagers and children. Seek a physician who works specifically with teenagers. physician who works specifically with teenagers.

Hospitalization Hospitalization may be necessary in situations where a may be necessary in situations where a teen needs constant observation and care to prevent teen needs constant observation and care to prevent self-destructive behavior. Hospital adolescent self-destructive behavior. Hospital adolescent treatment programs usually include individual, group treatment programs usually include individual, group and family counseling as well as medications. and family counseling as well as medications.

Helpguide.org: “Teen Depression”http://www.helpguide.org/mental/depression_teen.htm#symptoms

Take SUICIDE Seriously

Even if they are only thoughts about suicide take them seriously!

The risk of suicide increases in those with depression and it's important to take suicidal thoughts seriously.

What parents can do for their teen: Respond with love, kindness, and support

Repeatedly let your child know that you are there, whenever she or he needs you

Be gentle but persistent if your adolescent shuts you out

Do not criticize or pass judgment once the adolescent begins to talk

Encourage activity and praise efforts to socialize and be active Seek help from a doctor or mental health professional if the

adolescent's depressed feeling doesn't pass with time

Helpguide.org; “Teen Depressionhttp://www.helpguide.org/mental/depression_teen.htm#symptoms

Antidepressant SalesAntidepressant Sales

• Prescriptions for antidepressants have dropped by 20% for those 18 Prescriptions for antidepressants have dropped by 20% for those 18 y/o and younger since 2004 when FDA initial warnings were y/o and younger since 2004 when FDA initial warnings were publishedpublished

• Sales of antidepressants among adults were down 14% in 2005Sales of antidepressants among adults were down 14% in 2005

• Sales are climbing again in 2006Sales are climbing again in 2006

• Depression in children and adolescents is a serious problem with potentially disastrous outcomes

• Practical and effective approaches to assessment and treatment have now been organized

• Several well supported treatment options exist both pharmacologically and nonpharmacologically

• Antidepressants should be respected, but not feared

Take Home Message