Download Management of Adolescent Depression

Management of
Adolescent Depression
Richard Idell, M.D.
Prevalence
• 3 to 5 years – 0.5 percent
• 6 to 11 years – 1.4 percent
• 12 to 17 years – 3.5 percent
• Lifetime prevalence of depression in
adolescence 11%
Gender Differences
• 2:1 Female to Male ratio, emerges during
puberty
• Before puberty 60% higher in boys
Risk factors
●Low birth weight
●Family history of depression and anxiety
●Family dysfunction or caregiver-child conflict
●Exposure to early adversity (eg, abuse, neglect,
or early loss)
●Psychosocial stressors (eg, peer problems and
victimization [bullying], and academic difficulties)
Risk Factors
• Gender dysphoria and homosexuality, especially if
youth is bullied
• Negative style of interpreting events and coping with
stress
• History of anxiety disorders, substance use disorder,
learning disabilities, attention deficit hyperactivity
disorder, and oppositional defiant disorder
• Traumatic brain injury
• Chronic illness, especially if symptom and/or treatment
burden yields chronic life disruptions
Symptoms
• Several domains
– Psychological
– Physical
– Cognitive
• Leading to change in behavior
– Often what parents notice
– Adolescents tend to reports thoughts and feelings
more
Symptoms-5 “SIGECAPS”/2weeks
• Depressed or irritable mood
– Gloomy, hopeless, everything is unfair, feeling
helpless
– Annoyed, grouchy, bothered, negative
argumentative, low frustration tolerance
– Reactive mood- cheered up by positive events
• Thrill seeking, promiscuity, drug use
• Rumination with depressed peers
Symptoms
• Diminished interest or pleasure (anhedonia)
– hobbies, interests, and people as less interesting
or fun than previously
– "boring," "stupid," or "uninteresting.“
– Withdraw from friends
Symptoms
• Change in appetite or weight
– Failure to gain weight
– Weight gain
Web: Pro-ana, Pro- mia, ASH
• Ana- anorexia “support” (thinspiration)
• Bulimia- bulimia “support”
• ASH- suicide “pro-choice”
Symptoms
• Sleep disturbance insomnia, hypersomnia,
– Initial insomnia
– Middle insomnia
– Terminal insomnia
– Hypersomnia
– Circadian reversal
– Non-restorative sleep, tough to get up
Symptoms
• Psychomotor agitation or retardation
– inability to sit still; pacing; or pulling or rubbing
clothes, the skin, or other objects
– psychomotor retardation: talk or move more
slowly than is typical for them; in addition, speech
volume or inflection may be decreased, and the
amount of speech may be diminished.
– Noticeable to others
Symptoms
• Fatigue or loss of energy – Lack of energy
(anergia) manifests with feeling tired, exhausted,
listless, and unmotivated.
– Need to rest during the day, experience heaviness in
their limbs, or feel like it is hard to initiate activities.
– Parents may attribute lack of energy and motivation
to laziness, an oppositional attitude, or avoidance of
responsibilities.
– Parents concerned that the patient has a general
medical illness
Symptoms
• Feelings of worthlessness or guilt feelings of
inadequacy, inferiority, failure, worthlessness, and
guilt.
–
–
–
–
–
Self-critical
Discounting positive self-attributes
Dissatisfaction with themselves
Lying about success or skills to bolster self-esteem
Envy or preoccupation with the success of others,
especially in comparison with self-evaluation
– Belief that they deserve to be punished for things that are
not their fault
– Reluctance to try to do things because patients fear they
will fail, and decide “what’s the use?”
Symptoms
• Impaired concentration and decision making
• Not present before the depressive episode.
– Thinking and processing of information may be
slowed.
– indecisive, which manifests as procrastination,
helplessness, or ambivalence
– Longer to complete homework and class work
than before the depressive episode; school
performance may thus decline.
Recurring thoughts of death
• Recurring thoughts of death or suicide –
– Morbid thoughts are common in depressed teens
– Active suicidal ideation of wanting to die
– Hopelessness
Psychosis
• Psychosis – Major depression may include
delusions and hallucinations (command
auditory hallucinations telling patients to
commit suicide)
Functional impairment
• School functioning, parents and peers, and daily activities and
responsibilities.
– Risk for engaging in health risk behaviors such as promiscuity
• May reinforce and trigger new episodes:
–
–
–
–
–
Academic failure and school avoidance
Interpersonal dysfunction with family, peers, and teachers
Social withdrawal
Negative attributions about the perceptions or intent of others
Seeking reassurance excessively
• Most notable during adolescence, when most teens strive to define
themselves and establish a social role outside the family.
• Impact on psychosocial outcomes in adulthood is not clear; some
studies suggest adolescent depression is associated with functional
impairment in adults, whereas other studies do not.
Comorbidity
• 60%-one other disorder
• 50%- two disorders
– Anxiety disorders
– Attention deficit hyperactivity disorder (ADHD)
– Disruptive behavior disorders (eg, oppositional defiant
disorder and conduct disorder)
– Substance use disorders
– Eating disorders, learning disorders, and somatic
symptom disorders,
– Depressed patients are more likely to manifest health
problems
General Medical Problems
• General medical — depression in adolescence may be
associated with premature atherosclerosis and
cardiovascular disease.
• Increased inflammation, oxidative stress, and
autonomic dysfunction
• Cardiovascular risk factors: diabetes mellitus, obesity,
sedentary lifestyle, and tobacco smoking are more
prevalent among adolescents with major depression
compared with the general pediatric population
• Depression- moderate risk condition for early
cardiovascular disease
Course
• Children
– the average duration of depressive episodes ranged from 8 to 13 months
– relapse or recurrence occurred in 30 to 70 percent
• Adolescents
– average duration of depressive episodes ranged from four to nine months, and that 90
percent of the episodes remitted within two years
– one recurrence was observed in 20 to 70 percent
– Adolescents with major depression are more likely to suffer depression in adulthood,
compared with adolescents who are not depressed.
• Recurrence — Risk factors for recurrence of pediatric major depression
include:
–
–
–
–
–
–
History of prior depressive episodes
Presence of residual depressive symptoms
Presence of comorbid disorders
Environmental stressors
Limited social supports
Family history of recurrent unipolar major depression or other psychopathology
Assessment
• ASSESSMENT — psychiatric and general medical history,
mental status, and focused laboratory tests: thyroid
stimulating hormone, complete blood count, chemistries,
and urine toxicology to screen for substances of abuse
– Child or adolescent, parents and teachers, questionnaires (BDI
etc.)
– Culture
– Suicidal and homicidal ideation and behavior
– Look for comorbid conditions (psychiatric or physical)
– Evaluate precipitants, stressors, and academic, social, and family
functioning
– Resist the diagnosis of depression and continue to seek a
"medical" explanation for presenting symptoms.
– Diagnosis of depression as reassuring, potential for relief
Depression Diagnosis
• Major depressive disorder
• Persistent depressive disorder (dysthymia)
– low grade depression lasting years
• Unspecified depressive disorder
• Disruptive mood dysregulation disorder
– irritability, frequent major tantrums
• Premenstrual dysphoric disorder
• Substance/medication induced depressive disorder
• Depressive disorder due to another medical
condition
Specifiers
• Anxious distress
• Atypical features (teens)
•
Reactive to pleasurable stimuli (ie, feels better in response to positive events)
–
–
–
–
•
Increased appetite or weight gain
Hypersomnia (eg, sleeping at least 10 hours per day, or at least 2 hours more than usual when not
depressed)
Heavy or leaden feelings in limbs
Rejection sensitivity
Catatonia
–
Catatonic features are characterized by prominent psychomotor disturbances
•
Melancholic features- (elderly)
•
Loss of pleasure in most activities
–
–
–
–
–
–
Unreactive to usually pleasurable stimuli (ie, does not feel better in response to positive events)
Depressed mood marked by despondency, despair, or remorse
Early morning awakening (eg, two hours before the usual hour of awakening)
Psychomotor retardation or agitation
Anorexia or weight loss
Excessive guilt
Differential
• Adjustment disorder with depressed mood
– Stressor in past 3 months, sadness, impaired
functioning, doesn’t meet criteria for depression
• Bipolar depression
– Depression + episodic mania (not necessarily
mood swings throughout the day)
– Depression usually presents before mania
• Reactive mood/sadness
Treatment
• Safety
• Education
• Treatment plan
– Pharmacotherapy
– Psychotherapy
– Combination therapy (pharmacotherapy plus
psychotherapy)
– Assess psychosocial stressors, home, school, social
– Lifestyle
• Exercise, diet, stress reduction techniques
Initial treatment
• Combination therapy- TADS study
– Faster response (higher response rate at 12, 18
weeks, similar at 36)
– Prozac + CBT (widely studied)
– Sertraline + CBT or interpersonal psychotherapy
– Adolescents- Lexapro
• Therapy-improving adaptive behaviors and coping
skills, family and peer relationships, and self-esteem
(therapeutic alliance)
First line
• For children and adolescents with acute
depressive disorders, first line
pharmacotherapy is Fluoxetine.
• There is more consistent, high quality
evidence for the efficacy of fluoxetine than
other antidepressants
Why choose another medication
• Desire to avoid specific adverse effects
• Response to a different antidepressant during a
prior depressive episode
• Response to a different antidepressant by parent
or sibling
• Known hypersensitivity to fluoxetine in the
patient or family
• Patient and/or family preference
• Potential drug-drug interactions
Other options
•
•
•
•
Sertraline (Zoloft)
Lexapro (escitalopram)
Celexa (citalopram)
Then
– Venlafaxine, Bupropion, Cymbalta
• Lack of benefit
– Paxil, Tricyclics
Alternative treatments
• Anti-inflammatory
– Fish oil, probiotics
• Antioxidants/NRF2 activators
– N-Acetyl cysteine, Alpha lipoic acid,
Sulfurophane, Green tea extract, Curcumin
• St. John’s Wort/ SAMe
Maintenance
• 6-12 months
Adverse Effects-SSRI’s
• Abdominal pain
• Agitation, jitteriness, or akathisia (restlessness and inability
to sit still)
• Diarrhea
• Headache
• Nausea
• Sleep changes
• Cardiac events- very rare, qtc prolongation, with lexapro,
escitalopram
• Serotonin syndrome
• Suicidality (black box warning)
• Discontinuation syndrome
Adverse effects
Black box Warning
Impact
• Rates of depression diagnosed decreased
• Decrease in antidepressant prescriptions
• Suicide rates were decreasing since the 80’s
then…
• 2004-2005-largest increase in suicide rates
after black box warning implemented
• Suicide has continued to decline in pt’s age
60+
Treatment Resistance
•
•
•
•
•
•
Adequate dose titration
No response 6-12 weeks
Bipolar depression
Substance use
Non adherence (side effects)
Stressors
– Bullying, abuse, family conflict, peer conflict
Treatment Resistance-TORDIA study
• Failed SSRI
– Switch to another SSRI
– Or SNRI (venlafaxine, Cymbalta) potentially more
side effects
– Add psychotherapy
• Off label meds
– ECT (rarely used in adolescents)
Adjunctive treatment
•
•
•
•
•
•
Second generation antipsychotics (Abilify)
Buspar
Thyroid hormone
Stimulants
Bupropion
Trazodone, Remeron (more commonly used
for sleep, appetite)
Looking toward the future
• Fast acting antidepressants that work through
glutamate, ketamine and derivatives
• Subutex and Ketamine for suicidal ideation
• rTranscranial Magnetic Stimulation
• Optogenetics- triggering nerves by light
• Psychedelics- NYU, Johns Hopkins- Psilocybin
trials
• UTHNE- fibrinolysis and depression
Thanks
references
•
•
•
•
•
•
•
•
•
•
•
Uptodate.com:
Essau C, Dobson K. Epidemiology of depressive disorders. In: Essau C, Petermann F, eds. Depressive Disorders in
Children and Adolescents: Epidemiology, Course and Treatment. Northvale, NJ: Jason Aronson Inc; 1999:69-103
US Food and Drug Administrtion. Background on suicidality associated with antidepressant drug treatment.
Available at: www.fda.gov/ohrms/dockets/ac/04/briefing/2004-4065b1-04-Tab02-Laughren-Jan5.pdf (Accessed on
March 24, 2008).
Ambrosini PJ. A review of pharmacotherapy of major depression in children and adolescents. Psychiatr Serv 2000;
51:627.
Hetrick SE, McKenzie JE, Cox GR, et al. Newer generation antidepressants for depressive disorders in children and
adolescents. Cochrane Database Syst Rev 2012; 11:CD004851.
Emslie GJ, Rush AJ, Weinberg WA, et al. A double-blind, randomized, placebo-controlled trial of fluoxetine in
children and adolescents with depression. Arch Gen Psychiatry 1997; 54:1031.
Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one
or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163:1905.
Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National
Comorbidity Survey Replication (NCS-R). JAMA 2003; 289:3095.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
American Psychiatric Association, Arlington, VA 2013.
Keller MB. Issues in treatment-resistant depression. J Clin Psychiatry 2005; 66 Suppl 8:5.
Rush AJ, Warden D, Wisniewski SR, et al. STAR*D: revising conventional wisdom. CNS Drugs 2009; 23:627.