Depression in AdolescenceDepression in Adolescence

Topics To Be CoveredTopics To Be Covered

What is depression? Prevalence in adolescence

– Gender differences– Course of depression

What causes depression? How do we treat depression? Can we prevent depression?

What is Depression?What is Depression?

DSM-IV Criteria for Major Depressive Disorder

Unique Features for Children/Teens Dysthymic Disorder Diagnosis versus Depressed Mood

versus Depressive Syndrome

DSM-IV Major Depressive EpisodeDSM-IV Major Depressive Episode Persistent sad or irritable mood Loss of interest in activities Significant change in appetite or weight Difficulty sleeping or oversleeping Psychomotor agitation or retardation Loss of energy Worthlessness or excessive guilt Difficulty concentrating Recurrent thoughts of death or suicide

Common Manifestations in Adolescence

Common Manifestations in Adolescence

Frequent physical complaints--headaches, muscle aches, stomach aches, tired

Frequent absences from school, poor performance in school

Talk about or try to run away from home Shouting, complaining, irritability or crying for no

reason Alcohol or substance abuse Rumination Being bored, lack of interest in friends

Dysthymic DisorderDysthymic Disorder

Depressed or irritable most of the day, more days than not, for at least 1 year

Plus, at least 2 of the following:

– eating problems

– sleep problems

– low energy

– low self-esteem

– poor concentration/decision making

– Hopelessness Onset typically in childhood or adolescence Average duration in children/adolesc ~4 years 70% of those with dysthymia eventually develop Major Depressive

episode

Prevalence of Depression in AdolescencePrevalence of Depression in Adolescence

Major Depressive Disorder: 4.9% (of 9-17 year olds, from MECA study)

Depressed Mood: – Parents’ reports: approx. 15%– Adolescent reports: 25-30%

Gender Differences in DepressionGender Differences in Depression

Through age 12, no gender difference (or males slightly higher)

After age 12, girls more likely than boys to have depressive disorders, and depressed mood.

Difference: Girls 2 - 3x more depression than boys.

Why Gender Differences? Why Gender Differences?

Differences in risk factors/stresses for girls, e.g., assertiveness, ruminative coping style, body image stresses?

Course of Depressive IllnessCourse of Depressive Illness

• Depression is episodic. However, most youth experience a recurrence.

• 20 - 40% relapse within 2 years

• 70% relapse by adulthood

What Causes Depression?What Causes Depression?

Family History FactorsFamily History Factors

Family History of Depression– Between 20-50% of adolescents with

depression have a family history of it– Children of depressed parents are 3x more

likely to develop a depressive disorder Could be due to genetic factors, and/or

environmental– Parents may be unavailable, dysfunctional

interactions with child, family conflict.

Biological FactorsBiological Factors

Most work has been done with adults, little with adolescents or children.

Serotonin levels have been linked to depression in adults

Pituitary functions--increased cortisol and hypo- or hyperthyroidism--linked to adult depression (Implicated in vegitative symptoms, i.e., eating, sleeping)

Cognitive FactorsCognitive Factors

Pessimistic attributional bias– Person assumes blame for bad events– Overgeneralizes from one bad experience to a

pattern (everthing I do is wrong)– Believes problems will persist permanently

(Nothing will make it better) Unclear whether this bias precedes depression,

occurs simultaneously, or is a result of it. Once developed, the style tends to endure, possibly increasing the risk of future episodes.

PeersPeers

Low peer popularity, rejection by peer groups

Lack of closeness with a best friend Fewer supportive social relationships

Daily and Stressful Life EventsDaily and Stressful Life Events

Confluence of puberty and school change

Depressed adolescents report both more acute and more chronic stressors than youth with antisocial disorders, medical problems, or normal controls.

Bruce E. Compas

Interventions for Youth Depression

Interventions for Youth Depression

Psychosocial and PsychotherapeuticPsychosocial and Psychotherapeutic

Cognitive Behavioral, Psychodynamic, Family, and Supportive Group Therapy all shown to improve depressed mood

Most rigorous study was with Cognitive Behavioral Therapy– Showed 50% reduction in rate of Major

Depression in treatment group, relative to untreated

– Focus on cognitive distortions, generating ‘rational’ alternatives, positive events

MedicationMedication

Tricyclic anti-depressants were never shown to be effective with kids/teens

Currently, SSRI’s used. – First tested was fluoxetine. 56% improved significantly

(31% completely), versus 33% controls (23% completely). More effective than impramine (a tricyclic)

– In the large study TADS study (Treatment for Adolescents with Depression), combination of fluoxetine plus cognitive behavior therapy superior to either alone (next slide).

Medication c’t’dMedication c’t’d

The relative large gap between placebo & medication in previous slide is unusual in the literature– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.

Wagner et al.), 69% improved on medication vs. 59% placebo. Statistically significant, but sertraline made a difference only in ~10% of youth.

Negative results do not get published– E.g., 1 published study shows effectiveness of paroxetine.

However, 2 large unpublished studies found no effects, and twice the risk of suicidal ideation.

– 2 large trials of venlafaxine show it to be ineffective with adolescents, both unpublished.

Suicidal Symptoms in “TADS” studySuicidal Symptoms in “TADS” study

Suicidal ideation dropped fluoxetine group as well as all others.

But, 15/216 (6.94%) on fluoxetine exhibited suicidal behavior (e.g. attempt or threat), vs. 9/223 on placebo

FDA Warning on Suicide & antidepressant medicationsFDA Warning on Suicide & antidepressant medications

“Black box” warning required for all SSRI and tricyclic antidepressants.

In the FDA review, no completed suicides occurred among nearly 2,200 children treated with SSRI medications; however, the rate of suicidal thinking or behavior, including actual suicidal attempts, was 4 percent for those on SSRI medications, twice the rate of those on inert placebo pills (2 percent).