1. Diagnosis & Management of Adolescent Depression Stephen M
Diagnosis & Management of Adolescent Depression Stephen M. Strakowski, MD Associate Vice President, Regional Mental Health Professor & Chair, Psychiatry Dell Medical School University of Texas - Austin
Title slide.

2. Strakowski COI statement
DSMB Chair for Sunovion studies.
Medscape (WebMD) video ‘blogger’.

3. Major Depression in Teens
Affects 10% of year olds
Rates double between ages years.
<50% of affected youth get meaningful treatment
Even less in youth of color
Early peak in suicide in this age range
Young adults in general
Late adolescence in males specifically
More likely to be onset of other conditions
Bipolar disorder, schizophrenia, PTSD
Strakowski SM, Nelson EG. Major Depressive Disorder. Oxford U. Press, NY, NY 2015
Merikangeas KR, et al. JACAP 2010; 49:
Cummings JR, Druss BG. JACAP 2010; 50:

4. DSM 5 criteria for Major Depression
>5 of the following for 2 weeks and a change from previous
*Depressed (or irritable in teens) mood most of the day, nearly every day
*Anhedonia
Significant weight loss or change in appetite (fall of growth curve).
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive guilt.
Decreased concentration/indecisiveness
Recurrent thoughts of death or suicide
B. Clinically significant distress or impaired functioning.
C, D, E. Not due to substance or to another medical or psychiatric condition.
Specifiers – With: anxious distress, mixed, melancholic, atypical, mood-congruent psychotic, mood-incongruent psychotic features or cataonia; or with peripartum onset or seasonal pattern.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright © 2013). American Psychiatric Association.

5. Diagnostic differences in Teens
More irritability and agitation.
Less neurovegetative disruption (growth curve).
More suicidality than early/middle adults.
More likely to be harbinger of other conditions
Bipolar disorder, alcohol/drugs, trauma
Differences from ‘Teenage Angst’
Peer withdrawal, suicidality, neurovegetative
Failure at previous areas of importance to teen
Evolves during adolescence with prefrontal changes.
Strakowski SM, Nelson EG. Major Depressive Disorder. Oxford U. Press, NY, NY 2015

6. Successful Treatment:
7 Key components
Comprehensive Assessments*
Ongoing safety evaluations*
Setting treatment goals agreeable to teens!
Agreed upon treatment plan to meet goals*
A good support network (ideally peers)
Mood charting
Systematic, meaningful appointments
Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015.
Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

7. Comprehensive Assessments
Systematic psychiatric assessment (checklist)
Identify medical/psychiatric causes
Identify relevant family history (bipolar disorder)
Assess stressors (consider checklist)
Assess drug/alcohol use; don’t forget smoking
Suicide assessment
Good medical evaluation
Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015.
Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

8. Suicide Risk: Safety Evaluation
Risk Factors
Prior suicide attempts
Family history of suicide
Suicidal ideation
Hopelessness
Drug/Alcohol abuse
Anxiety/Panic attacks
Psychosis
Personality disorder
Recent loss/major life stressor
Medical illness
Protective Factors
Supportive family/children at home
Strong religious beliefs
Strong social support
Future oriented
Good coping skills
Ongoing mental health care
Limited access to highly lethal methods of suicide (e.g., guns)
Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015.
Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

9. Agreed upon treatment plan to meet goals
Set goals meaningful to the teen
Try managing cause alone vs. start treatment
Three major choices
Therapy only (stressors, functional goals)
Meds only (medical or idiopathic, symptom goals)
Combination
See patient again within 2 weeks of initiating
One change at a time
PCPs will manage most depression
Dose adequately
Be patient and understand response
Complex or failed 2 trials consider referral
Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015.
Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

10. Fluoxetine in Pediatric Depression
Treatment for Adolescents with Depression (TADS) Study
439 randomized teens age years
CBT v. fluoxetine v. combination
Response rates:
Fluoxetine + therapy 71% >
Fluoxetine alone 61%>
Therapy alone 43%
Placebo alone 35%
March J et al. JAMA Aug 18;292(7):

11. Antidepressant treatment response
6-8 weeks
Mood
Time
Treatment starts

12. Antidepressant treatment response
6-8 weeks
Mood
Time
Treatment starts

13. Antidepressant treatment response
6-8 weeks
Mood
Time
Treatment starts

14. TAY Approved Antidepressants
     Brand Name Generic Name Approved Age
     Anafranil clomipramine 10 and older (for OCD)
Celexa citalopram 18 and older
     Effexor venlafaxine 18 and older
Lexapro escitalopram 18 and older
     Luvox fluvoxamine   8 and older (for OCD)
     Paxil paroxetine 18 and older
     Prozac fluoxetine 7 and older (for depression)
Remeron mirtazapine 18 and older
     Serzone nefazodone 18 and older
     Sinequan doxepin 12 and older
     Tofranil imipramine   6 and older (for bed-wetting)
     Wellbutrin bupropion 18 and older
     Zoloft sertraline   6 and older (for OCD)

15. SSRIs in Children Advisory
2004: FDA orders black box warning on SSRIs
Meta-analysis of 372 studies increased from 2-4% in SI, no attempts, if <18.
2007: modified to acknowledge depression increased suicide risk (15% in adults).
2004: decreased SSRI prescribing
Subsequent increased drug poisonings?!
Risk of untreated depression>>risk of SSRIs
SSRIs are effective, but monitor use.

16. Psychotherapy for Adolescent Depression
Psychotherapy is recommended for treatment of adolescent depression
Cognitive Behavioral Therapy (CBT): best evidence
Interpersonal Therapy (IPT): good evidence
Psychodynamic Psychotherapy: limited evidence
Lifestyle management: minimal evidence, but low risk
Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford U. Press, NY 2014.
Clark et al. Am Fam Physician 2012; 86:

17. A Brief Guideline for Treatment of Adolescent Depression
Optimize current or start new treatment
1st line: fluoxetine, established SSRIs, CBT, IPT
1bst line: SNRIs, Bupropion
2nd line: mirtazapine, levomilnacipran, vilazodone, vortioxetine
3rd line: ECT, rTMS, VNS, DBS, TCAs, MAOIs, ?Ketamine
Switch (no response in 4-6 weeks)
Augment (partial response)
1st line: Antidepressant combination, lithium, CBT, IPT
2nd line: thyroid hormone, approved atypical antipsychotic
3rd line: stimulants, ECT, Ketamine, rTMS
3 drug maximum (combos probably need referral)
Avoid frequent changes (be systematic)

18. Questions?