1. Depression in Adolescence

2. Topics To Be Covered n What is depression? n Prevalence in adolescence –Gender differences –Course of depression n What causes depression? n How do we treat depression? n Can we prevent depression?

3. What is Depression? n DSM-IV Criteria for Major Depressive Disorder n Unique Features for Children/Teens n Dysthymic Disorder n Diagnosis versus Depressed Mood versus Depressive Syndrome

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

5. Common Manifestations in Adolescence n Frequent physical complaints--headaches, muscle aches, stomach aches, tired n Frequent absences from school, poor performance in school n Talk about or try to run away from home n Shouting, complaining, irritability or crying for no reason n Alcohol or substance abuse n Rumination n Being bored, lack of interest in friends

6. Dysthymic Disorder n Depressed or irritable most of the day, more days than not, for at least 1 year n Plus, at least 2 of the following: –eating problems –sleep problems –low energy –low self-esteem –poor concentration/decision making –Hopelessness n Onset typically in childhood or adolescence n Average duration in children/adolesc ~4 years n 70% of those with dysthymia eventually develop Major Depressive episode

7. Prevalence of Depression in Adolescence n Major Depressive Disorder: 4.9% (of 9- 17 year olds, from MECA study) n Depressed Mood: –Parents’ reports: approx. 15% –Adolescent reports: 25-30%

8. Gender Differences in Depression n Through age 12, no gender difference (or males slightly higher) n After age 12, girls more likely than boys to have depressive disorders, and depressed mood. n Difference: Girls 2 - 3x more depression than boys.

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

10. Course of Depressive Illness Depression is episodic. However, most youth experience a recurrence. 20 - 40% relapse within 2 years 70% relapse by adulthood

11. What Causes Depression?

12. Family History Factors n 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 n Could be due to genetic factors, and/or environmental –Parents may be unavailable, dysfunctional interactions with child, family conflict.

13. Biological Factors n Most work has been done with adults, little with adolescents or children. n Serotonin levels have been linked to depression in adults n Pituitary functions--increased cortisol and hypo- or hyperthyroidism--linked to adult depression (Implicated in vegitative symptoms, i.e., eating, sleeping)

14. Cognitive 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) n 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.

15. Peers n Low peer popularity, rejection by peer groups n Lack of closeness with a best friend n Fewer supportive social relationships

16. Daily and Stressful Life Events n Confluence of puberty and school change n Depressed adolescents report both more acute and more chronic stressors than youth with antisocial disorders, medical problems, or normal controls. Bruce E. Compas

17. Interventions for Youth Depression

18. Psychosocial and Psychotherapeutic n Cognitive Behavioral, Psychodynamic, Family, and Supportive Group Therapy all shown to improve depressed mood n 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

19. Medication n Tricyclic anti-depressants were never shown to be effective with kids/teens n 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).

21. Medication c’t’d n 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. n 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.

22. Suicidal Symptoms in “TADS” study n Suicidal ideation dropped fluoxetine group as well as all others. n But, 15/216 (6.94%) on fluoxetine exhibited suicidal behavior (e.g. attempt or threat), vs. 9/223 on placebo

23. FDA Warning on Suicide & antidepressant medications n “Black box” warning required for all SSRI and tricyclic antidepressants. n 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).