Download ppt: depression

Understanding
Depression
Why talk about depression?
 Recent surveys suggest, according to Mental Health
America
 1 in 5 teens suffers from Clinical Depression
 Each year almost 5,000 young people (ages 1524) commit suicide
 Rate has tripled since 1960 – 3rd leading cause of
death in adolescents and 2nd leading cause of
death among college age
Understanding Teen Depression
 There are as many misconceptions about
teen depression as there are about
teenagers in general.
 Yes, the teen years are tough, but most
teens balance the requisite angst with
good friendships, success in school or
outside activities, and the development of
a strong sense of self
Why are Adolescents So
Vulnerable??
Why are Adolescents so Vulnerable?
Adolescence represents one of the healthiest
periods in life span with respect to physical
illness BUT


200-300% increase in mortality and morbidity rates
between mid childhood to late adolescence
Problems related to control of emotions and behavior:
• Accidents, homicides
• Suicide, depression, anorexia, bulimia
• Alcohol and substance use
• STDs, unwanted pregnancies
Why are Adolescents so Vulnerable?
Adolescence period of rapid changing in CNS
 Structural changes occurring in this time period:
• Completion of brain cell genesis, nerve
myelination, dendrite pruning in the frontal
cortex
• These developments in turn lay the foundation
for more sophisticated “executive function”
problem solving skills
Why are Adolescents so Vulnerable?
Pubertal development assoc with changes in brain:
 Changes in Brain assoc. with behavioral changes
• Animal models--sensation seeking
• Adolescents—mood regulation, romantic
interests, changes in sleep/wake cycles, risk
taking (DAHL, 2009)
MECHANISM: Rise in estrogen availability during
puberty—may impact the functional integrity of
the amygdala and prefrontal cortex
Why are Adolescents so Vulnerable?

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Emotional changes associated with pubertal
development (emotional intensity, romantic
interests, risk taking)
Cognitive changes (inhibitory control, problem
solving, long term planning) are more related to
increasing age and experience
Why are Adolescents so Vulnerable?

Asynchrony between physical and emotional
changes and cognitive maturation
 During this period of rapid change, adolescents are not
yet able to make rational decisions in the face of
intense emotional and motivational states
 Prone to biased interpretations of experiences, self-
criticality, low inhibitory control, and emotion-focused
coping
Understanding Teen Depression
 Occasional bad moods or acting out is to
be expected, but depression is
something different.
 Depression can destroy the very essence
of a teenager’s personality, causing an
overwhelming sense of sadness, despair,
or anger.
Theories of Depression
Onset, Course, and Outcome
 Onset may be gradual or sudden
 Usually
a history of milder episodes that
do not meet diagnostic criteria
 Age of onset usually between 13-15
years
 Average episode lasts eight months
 Longer
duration if a parent has a history
of depression
Onset, Course, and Outcome
 Most children eventually recover
from initial episode, but the disorder
does not go away
 Chance
of recurrence is 25% within one
year, 40% within two years, and 70%
within five years
 About one-third develop bipolar
disorder within five years after onset of
depression (bipolar switch)
 Overall outcome is not optimistic
What is Depression?
 Sadness is a normal reaction to life’s struggles,
setbacks, and disappointments.
 Depression is different from normal sadness by:
 Engulfing your day-to-day life,
 Interfering with your ability to work, study, eat, sleep,
and have fun.
 The feelings of helplessness, hopelessness, and
worthlessness are intense and unrelenting, with little, if
any, relief.
Gender, Ethnicity, and Culture
 No gender differences until puberty; then,
females are two to three times more likely
to suffer from depression;
 Symptom presentation is similar for both
sexes, although correlates of depression
differ for the sexes
 Physical, psychological, and social
changes are related to the emergence of
sex differences in adolescence
Gender, Ethnicity, and Culture
Risk of Depression by Age & Sex
0.014
Female
Male
Hazard rate
0.012
0.010
0.008
0.006
0.004
0.002
0.000
0-4
5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
Age (y)
Symptoms of Depression
 Vary from person to
person
 2 key signs are loss of
interest in things you
like to do and sadness
or irritability
Learned Helplessness
 Learned helplessness: when experience with
uncontrollable events can lead to the expectation that
no responses in one’s repertoire will control future
outcomes.

Have a maladaptive explanatory style (MES)
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Explain bad events as internal, stable, and global.
Helplessness deficits: motivational, cognitive, and emotional.
 Martin Seligman’s past research found that MES
was significantly correlated w/ high depression
scores.

Missing link: how do life events play into this?
Common Signs and Symptoms
 Feelings of helplessness and hopelessness
 Loss of interest in daily activities
 Appetite or weight changes
 Sleep changes
 Anger or irritability
 Loss of energy
 Self-loathing
 Reckless behavior
 Concentration problems
 Unexplained aches and pains
Depression in teens
 Some appear sad – most appear irritable
 Poor performance in school
 Withdrawal from friends and activities
 Anger/rage
 Overreaction to criticism
 Suicidal thoughts
 Poor self-esteem or guilt
 Substance abuse or acting out to avoid feelings
Changes in behavior and thinking
 These may include:
 General
slowing down
 Neglect of responsibilities and appearance
 Poor memory
 Inability to concentrate or think clearly
 Suicidal thoughts, feelings, or behaviors
 Difficulty making decisions
 Negative attitude and outlook
Have you ever heard these statements?
"I don't enjoy being with my friends or doing any of the
things I usually love to do."
"I feel sad all the time and just don't feel like myself."
"I've been having a lot of trouble sleeping lately."
What causes Depression?
 Family History
 Having
a family members who has
depression may increase a person’s
risk
 Imbalances of certain chemicals in
the brain may lead to depression
 Major Life Changes
 Positive
or negative
events can trigger
depression. Examples
include the death of a
loved one or a
promotion.
 Major Illnesses such
as heart attack, stroke
or cancer may trigger
depression.
 Certain
medications used
alone or in combination can
cause side effects much like
the symptoms of depression.
 Use of Alcohol or other Drugs
can lead to or worsen
depression.
 Depression can also occur for
no apparent reason!
Physical Complaints
 These may include:

Sleep disturbances such as early
morning waking, sleeping too much or
insomnia
 Lack of energy
 Loss of appetite
 Weight loss or gain
 Unexplained headaches or
backaches
 Stomachaches, indigestion or
changes in bowl habits
Common Types of Depression (DSM-V)
 Major Depression Disorder
 Substance/Medication-Induced Depressive
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Disorder
Persistent Depressive Disorder (formerly,
Dysthymia)
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
Other Specified Depressive Disorder
Unspecified Depressive Disorder
What is MDD?
DSM-5 sets 3 criteria:
A
5+ symptoms present in same 2-week
period, where at least one symptom is
(1) depressed mood or
(2) loss of interest or pleasure.
The rest of the symptoms may include:
 Depressed mood most of the day nearly every day.
•
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In children/adolescents, can be irritable mood.
Diminished interest/pleasure in all or almost all activities
most of the day nearly every day.
Weight loss, weight gain, decrease/increase in appetite.
• In children, failure to make expected weight gain.
Insomnia/hypersomnia.
Psychomotor agitation/retardation.
Fatigue or loss of energy.
Feelings of worthlessness or excessive or inappropriate
guilt.
Diminished ability to think or concentrate, or
indecisiveness.
Recurrent thoughts of death, recurrent suicidal ideation,
suicide attempts, or suicide plans.
B
 The symptoms
cause clinically
significant
distress/impairme
nt in social,
occupational, or
other important
areas of
functioning.
C
 The episode is
not attributable to
the physiological
effects of a
substance or to
another medical
condition.
Why is adolescent depression
significant?
Epidemiology:
 Point prevalence ranges from 3%-9%.
 By age 18, 20% of teens have had a
depressive episode.
 Incidence increases with age.
 No gender differences in children, 2:1
ratio of girls to boys in adolescence and
adults
Recovery
 Average length of
an episode of MDD
in children and
adolescents was 7
to 9 months.
 Approximately 90%
of MDD episodes
remit within two
years post onset.
Masking Behaviors
 Could be:
 Conduct
disorders (hyperactivity,
delinquency, aggressiveness, irritability)
 Psychological reactions
 Somatic complaints (headaches,
stomachaches, enuresis)
 School problems (school phobia, poor
performance)
Cost of Illness
 Annual cost of depressive disorders in
US is about $210 billion.
 85%
attributed to MDD, including costs of
treatment, absenteeism from work, losses
productivity, and premature death.
 70-80% of depressed teenagers do not
receive treatment.
Comorbidity
 As many as 90% of young people with depression
have one or more other disorders; 50% have two
or more
 Most common comorbid disorders include:
 Anxiety disorders (especially GAD), specific
phobias, and separation anxiety disorders
 Depression and anxiety are more visible as
separate, co-occurring disorders:
 As severity of the disorder increases and the
child gets older
Comorbidity (cont'd.)
 Other common comorbid disorders are:

Dysthymia, conduct problems, ADHD, and
substance-use disorder
 60% of adolescents with MDD have comorbid
personality disorders, especially borderline
personality disorder
 Pathways to comorbid conditions may differ by
disorder/sex
Monoamine Deficiency Hypothesis
 Postulates there
is a deficiency in
serotonin or
norepinephrine
neurotransmission
in the brain.
Major Neurotransmitters
Serotonin
Norepinephrine
Energy
Interest
Anxiety
Irritability
Mood,
Emotion,
Cognitive
Motivation function
Impulsivity
Sex
Appetite
Aggression
Drive
Dopamine
Role of Serotonin in the CNS
 Serotonin influences a wide variety of brain
functions
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Mood
Sleep
Cognition
Sensory perception
Temperature regulation
Nociception (e.g., migraine headache)
Appetite
Sexual behavior
Role of Dopamine in the CNS
 Dopamine modulates various brain functions

Mood

Cognition

Motor function

Drive

Aggression

Motivation
Role of Norepinephrine in the CNS
 Norepinephrine plays an important role in the
brain affecting

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Mood
Learning and memory
Regulation of sleep-wake cycle
Regulation of hypothalamic-pituitary axis
Regulation of sympathetic nervous system
Antidepressant Warnings
 All patients being treated with
antidepressants for any indication should be
monitored closely for:
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Clinical worsening
Suicidality
Unusual changes in behavior
 Monitoring of these patients especially during
the initial few months of a course of drug
therapy, or at times of dose changes, either
increases or decreases.
Hypothalamic-PituitaryCortisol Hypothesis
 Abnormalities in
the cortisol
response to stress
may underlie
depression.
Hypothalamic-Pituitary-Cortisol
Hypothesis
 There is convincing evidence that environmental
stress plays a significant role in modifying both
mental and physical health.
 The biological mechanisms linking stress to ill health
are not fully understood, but significant evidence
points to a central role of the stress axes; the
hypothalamic–pituitary–adrenal (HPA) axis and the
sympathetic nervous system.
 Together these two systems link the brain and the
body and are crucial in maintaining homeostasis as
well as improving an organism’s survival chances in
the face of environmental challenge
Amygdala Activity
 Roberson-Nay et al (2006) hypothesized
that there would be hyperactivity in the
amygdala of MDD adolescents.
 Results: MDD showed greater left
amygdala activation and poorer memory
performance in comparison to healthy
control group.
Temperament?
 DSM-5 labels neuroticism and negative
affectivity as a “well-established risk
factor” for MDD.
 Individuals
higher in neuroticism are more
likely to experience an MDD should a
stressful life event occur.
 Learned Helplessness
Monoamine Oxidase Inhibitors (MAOIs)
 MAOIs were the first class of antidepressants to be
developed. They fell out of favor because of concerns
about interactions with certain foods and
numerous drug interactions. MAOIs elevate the levels
of norepinephrine,serotonin, and dopamine by
inhibiting an enzyme called monoamine oxidase.
Monoamine oxidase breaks down norepinephrine,
serotonin, and dopamine. When monoamine oxidase
is inhibited, norepinephrine, serotonin, and dopamine
are not broken down, increasing the concentration of
all three neurotransmitters in the brain.
Treatment: SSRIs
Tricyclic Antidepressants
Tricyclic Antidepressants
 Tricyclic antidepressants
consistently fail to demonstrate any
advantage over placebo in treating
depression in youth & adolescents
 They
have potentially serious
cardiovascular side effects
Selective Serotonin Reuptake
Inhibitors (SSRIs)
Serotonin - Specific Reuptake
Inhibitors (SSRI’s)
 Available for the past 15 years
 Allows for more serotonin to be
available to stimulate postsynaptic
receptors
 Available to treat depression, anxiety
disorders, ADHD, obesity, alcohol
abuse, childhood anxiety, etc.
Treatment: SSRIs
Treatment: SSRI’s
 Fluoxetine (Prozac) – first SSRI available, long half
life, slow onset of action, can cause sexual
dysfunction, anxiety, insomnia and agitation
 Sertraline (Zoloft) – second SSRI approved, low risk
of toxicity, few interactions, more selective and potent
than Prozac
 Paroxetine (Paxil) – third SSRI available, more
selective than Prozac, highly effective in reducing
anxiety and posttraumatic stress disorder (PTSD) as
well as OCD, panic disorder, social phobia,
premenstrual dysphoric disorder, and chronic
headache
SSRI’s
 Fluvoxamine (Luvox) – structural derivative
of Prozac, became available for OCD, also
treats PTSD, dysphoria, panic disorder, and
social phobia
 Citalopram (Celexa) – well absorbed orally,
few drug interactions, treats major
depression, social phobia, panic disorder and
OCD
SSRI Results
 SSRI
improvement
was statistically
and clinically
significant
compared to
placebo.
 Effect
size=2.9
Treating Teen Depression
 Medication - relieves some symptoms of depression
and is often prescribed with therapy
 Cognitive-behavioral therapy - challenges negative
thinking and behaving patterns
 Interpersonal therapy - focuses on developing
healthier relationships at home and school
 Psychotherapy - explore events and feelings that
are painful or troubling; learn coping skills
Psychosocial Interventions
 Behavior therapy
 Focuses
on increasing pleasurable
activities and events, and providing the
youngster with the skills necessary to
obtain more reinforcement
 Cognitive therapy
 Teaches
depressed youngsters to
identify, challenge, and modify negative
thought processes
Cognitive Behavioral Therapy
 Principle
of CBT is that thoughts influence
behaviors and feelings, and vice versa.
 Treatment
targets patient’s thoughts and
behaviors to improve his/her mood.
 Essential
elements of CBT include
increasing pleasurable activities
(behavioral activation), reducing negative
thoughts (cognitive restructuring), and
improving assertiveness and problemsolving skills to reduce feelings of
hopelessness.
Interpersonal Therapy-Adolescent

Principle of IPT-A is that interpersonal
problems may cause or exacerbate
depression and that depression, in turn, may
exacerbate interpersonal problems.

Treatment will target patient’s interpersonal
problems to improve both interpersonal
functioning and his/her mood.

Essential elements of interpersonal therapy
include identifying an interpersonal problem
area, improving interpersonal problem-solving
skills, and modifying communication patterns.
Psychotherapy
Psychotherapy
 This can help many depressed people
understand themselves and cope with
their problems. For example:
 Interpersonal
therapy works to change
relationships that affect depression
 Cognitive-behavioral therapy helps people
change negative thinking and behavior
patterns
Who can really be a psychotherapist?
Adequately trained and certified:
 Nurse practitioner
 Psychiatrist
 Physician assistant
 Psychologist
 Minister, priest
 Social worker
Untrained persons not tested for
competence!
 anyone can call themselves a
“therapist!”
What is psychotherapy?
 Interpersonal, relational intervention by
trained therapists to aid in life problems
 Goal: increase sense of well-being, reduce
discomfort
 Employs range of techniques based on
relationship building, dialogue,
communication and behavior change designed
to improve the mental of individual patient or
group
What is psychotherapy?
 Some therapies focus on changing current
behavior patterns
 Others emphasize understanding past
issues
 Some therapies combine changing
behaviors with understanding motivation
 Can be short-term with few meetings, or
with many sessions over years
What is psychotherapy?
 Can be conducted with individual, couple,
family or group of unrelated members who
share common issues
 Also known as talk therapy, counseling,
psychosocial therapy or, simply, therapy
 Can be combined with other types of
treatment, such as medications
What can psychotherapy accomplish?
 Learn to identify and change behaviors or
thoughts that adversely affect life
 Explore and improve relationships
 Find better ways to cope and solve problems
 Learn to set realistic goals
All psychotherapies provide:
 A working alliance between patient and
therapist
 An emotionally safe setting where the patient
can feel accepted, supported, un-criticized
 A therapeutic approach that may either be
strictly adhered to or modified according to
patient needs
 Confidentiality as integral to therapeutic
relationship except with safety issues
Disruptive Mood
Dysregulation Disorder
(DMDD)
Disruptive Mood Dysregulation Disorder
 Disruptive mood dysregulation disorder
(DMDD) is a childhood condition of extreme
irritability, anger, and frequent, intense temper
outbursts.

DMDD symptoms go beyond a being a “moody”
child—children with DMDD experience severe
impairment that requires clinical attention.
 DMDD is a fairly new diagnosis, appearing for
the first time in the DSM-V (2013)
Disruptive Mood Dysregulation Disorder
 Signs and Symptoms
 DMDD symptoms typically begin before the
age of 10, but the diagnosis is not given to
children under 6 or adolescents over 18.
 A child with DMDD experiences:

Irritable or angry mood most of the day, nearly
every day
Disruptive Mood Dysregulation Disorder
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Irritable or angry mood most of the day, nearly
every day
Severe temper outbursts (verbal or behavioral) at
an average of three or more times per week that
are out of keeping with the situation and the child’s
developmental level
Trouble functioning due to irritability in more than
one place (e.g., home, school, with peers)
To be diagnosed with DMDD, a child must have
these symptoms steadily for 12 or more months.
DMDD Prevalence: DSM V
 Unclear estimates for full DMDD criteria
 Estimates for chronic and severe
irritability:
6
mo.- 1 year period= 2-5%

Higher in males and school age children
Treatment of Depression Summary
Treatment of Depression Summary
Premenstrual Dysphoric Disorder
Premenstrual Dysphoric Disorder
 At least 5 core symptoms (including 1 or more of the
first 4 symptoms) in the final week before menses
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Clinically significant distress or interference with function
Not due to another disorder
Symptoms confirmed in at least 2 cycles vs. provisional
Not due to a substance
 Core Symptoms – Affective lability – Irritability –
Depressed mood – Anxiety/tension – Decreased
interest – Poor concentration – Fatigue – Appetite
change – Hypersomnia/insomnia – Overwhelmed –
Breast tenderness/joint swelling/bloating/weight gain
Treatment of Depression Summary
Persistent Depressive Disorder
(formerly, Dysthymia)
Persistent Depressive Disorder [P-DD]
(Dysthymia)
 Is characterized by symptoms of
depressed mood that occur on most days,
and persist for at least one year
 Child with P-DD also displays at least
two somatic or cognitive symptoms
 Symptoms are less severe, but more
chronic than MDD
Persistent Depressive Disorder
 Characterized by poor emotion
regulation
 Constant
feelings of sadness, of being
unloved and forlorn, self-deprecation,
low self-esteem, anxiety, irritability,
anger, and temper tantrums
 Children with both MDD and P-DD are
more severely impaired than children
with just one disorder
Prevalence
 Rates of P-DD are lower than MDD

Approximately 1% of children and 5% of
adolescents display P-DD
 Most common comorbid disorder is MDD
 Nearly 70% of children with DD may have an
episode of major depression
 About 50% of children with P-DD
 Also have one or more nonaffective disorders
that preceded dysthymia, e.g., anxiety
disorders, conduct disorder, or ADHD
Onset, Course, and Outcome
 Most common age of onset 11-12 years
 Childhood-onset dysthymia has a prolonged
duration, generally 2-5 years
 Most recover, but are at high risk for developing
other disorders:
 MDD, anxiety disorders, and conduct disorder
 Adolescents with P-DD receive less social
support than those with MDD
Treatment of Depression Summary
Adolescent Warning Signs
 Most symptoms are similar to those in adulthood
 Depression can be difficult to diagnose in teens
because adults may expect teens to act moody
 Adolescents do not always understand or express
their feelings well - they may not be aware of the
symptoms and may not seek help
What to Look For
 These symptoms may indicate depression:
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Poor performance in school
Withdrawal from friends and activities
Sadness and hopelessness
Lack of enthusiasm, energy or motivation
Anger and rage
Overreaction to criticism
Feelings of being unable to satisfy ideals
Poor self-esteem or guilt
Indecision, lack of concentration or forgetfulness
Restlessness and agitation
Changes in eating or sleeping patterns
Substance abuse
Problems with authority
Suicidal thoughts or actions
Red Flags
 Teens may experiment with drugs or alcohol or
become sexually promiscuous to avoid feelings of
depression
 Teens also may express their depression through
hostile, aggressive, and/or risk-taking behavior
 Such behaviors often lead to new problems, deeper
levels of depression, and destroyed relationships
Take SUICIDE Seriously
The risk of suicide increases in those with
depression and it's important to take suicidal
thoughts seriously.
Suicide Warning Signs in Teenagers
* Talking or joking about committing suicide.
* Saying things like, “I’d be better off dead,” “I wish I could
disappear forever,” or “There’s no way out.”
* Speaking positively about death or romanticizing dying (“If I
died, people might love me more”).
* Writing stories and poems about death, dying, or suicide.
* Engaging in reckless behavior or having a lot of accidents
resulting in injury.
* Giving away prized possessions.
* Saying goodbye to friends and family as if for good.
* Seeking out weapons, pills, or other ways to kill themselves.