Transcript Preventive Services Improvement Initiative

Depression Overview
Developed by the Center for School Mental Health with support
provided in part from grant 1R01MH71015-01A1 from the National
Institute of Mental Health and Project # U45 MC00174 from the
Office of Adolescent Health, Maternal, and Child Health Bureau,
Health Resources and Services Administration, Department of Health
and Human Services
Depressive Disorders
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Major Depressive
Disorder
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Dysthymic Disorder
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Depressive Disorder
Not Otherwise
Specified (NOS)
Depression
Epidemiology
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2.5% of children, up to 5% of adolescents
Prepubertal-1:1/F:M; adolescence-4:1/F:M
Average length of untreated Major Depressive
Disorder – 7.2 months
Recurrence rates-40% within 2 years
Heredity
Most important risk factor for the development of
depressive illness is having at least one affectively
ill parent
Depression
Modifications in DSM- IV for children:
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irritable mood (vs. depressive mood)
observed apathy and pervasive boredom (vs. anhedonia)
failure to make expected weight gains (rather than
significant weight loss)
somatic complaints
social withdrawal
declining school performance
What type of depression??
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Tonya has come for an initial appointment to the
SBHC. During the risk assessment, Tonya reports
a number of depressive symptoms, including
suicidal ideation. Tonya seems to display a lot of
negative thinking and cognitive distortions. For
example, she believes that “nobody” likes her
and that she will “never” be successful in school.
Her math teacher often compliments her work,
but Tonya dismisses the teacher’s comments as
him “just trying to be nice.” Tonya has good
grades in all classes except for one, yet she only
acknowledges her below average Chemistry
grade. Tonya has felt extremely sad for about
three weeks, which is a contrast from her usually
happy disposition.
Major Depressive Disorder
Major Depressive Episode:
Five (or more) of the following symptoms have been present during the same
two-week period and represent a change from previous functioning. At least
one symptom is either (1) depressed mood or (2) loss of interest or pleasure.
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Depressed mood most of the day, nearly every day, as indicated by subjective report
or based on the observations of others. In children and adolescents, this is often
presented as irritability.
Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day
Significant weight loss when not dieting or weight gain (change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (observable by others)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or inappropriate guilt nearly every day
Diminished ability to think, concentrate, make a decision nearly every day
Recurrent thoughts of death, recurrent suicidal ideation with or without a specific
plan, or an actual suicide attempt
Major Depressive Disorder
II. Symptoms cause clinically significant distress
or impairment in social or academic functioning
III. Symptoms are not due to the direct
physiological effects of a substance (drugs or
medication) or a general medical condition
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Although there is a different diagnostic category
for individuals who suffer from Bereavement,
many of the symptoms are the same and
counseling techniques may overlap.
What type of depression??
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Maria comes for a follow-up appointment
to the SBHC. Her risk assessment showed
that she has felt sad or blue for at least two
weeks. Upon further inquiry, Maria reports
that she generally feels sad, and finds little
enjoyment in activities. She reports having
felt this way for several years. In fact, she
can’t recall a time when she didn’t feel
mostly down. She denies suicidal ideation,
and is doing pretty well in school. She is
not very social, but does have a few
friends.
Dysthymic Disorder
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Major difference between a diagnosis of Major
Depressive Disorder and Dysthymia is the intensity
of the feelings of depression and the duration of
symptoms.
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Dysthymia is an overarching feeling of depression
most of the day, more days than not, that does not
meet criteria for a Major Depressive Episode.
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Impairs functioning and lasts for at least one year in
children and adolescents, two in adults.
Depressive Disorder NOS
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Disorders with depressive symptoms BUT do not meet
criteria for: Major Depressive Disorder, Dysthymic
Disorder, Adjustment Disorder with Depressed Mood, or
Adjustment Disorder with Mixed Anxiety and Depressed
Mood
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Examples: premenstrual dysphoric disorder, minor
depressive disorder (at least 2 weeks, but < 5 symptoms)
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Also used in situations in which clinician has concluded
that a depressive disorder is present, but is unable to
determine whether it is primary, due to medical condition,
or substance induced
Depression Versus Normal
Adolescent Development
Adolescent Development
Adolescent Development
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Periods of transient milder problems with
low self-esteem, anxiety, depressive feelings
are quite common.
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Needs to be differentiated from clinical
depression!
Depression and Suicide
Suicide
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Attempts- 3:1/F:M, Completions- 4:1/M:F
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Most common means of completed suicide:
FIREARMS
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Most often associated with depressive disorder.
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Risk factors: Age, sex, presence of psychiatric
illness, family history, isolation from friends,
substance abuse
Adolescents and Suicide
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In 1998, 4,153 young people, ages
15-24, committed suicide in the United
States an average of 11.3 per day.1
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Suicide is the third leading cause of death
in this age group following unintentional
injury and homicide2
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Suicide accounts for 13.5% of all deaths in
this age-group1
Murphy, SL, 1998
1999
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The Surgeon General’s Call to Action to Prevent Suicide,
Mortality in Children
Ages 1-19 years
Suicide
Homicide
Accidents
Cancer
Congenital
Other
Source: CDC Wonder Mortality Statistics; Center for Disease Control and Prevention, 2001
MH interventions shown to be
EFFECTIVE for depressive or
withdrawn behavior problems
 “Of
the available services
reviewed, Cognitive Behavioral
Therapy remains the intervention
of choice… Interpersonal Therapy
appears to be a reasonable
alternative to CBT”
What is Cognitive Behavior Therapy (CBT)?
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Relatively short-term, focused
psychotherapy
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Focus:
– How you are thinking (your cognitions)
– How you are behaving and communicating
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Emphasis on present rather than past
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Learn coping skills
What is Interpersonal Therapy (IPT)?
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Short term, usually involves up to 20 sessions
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Focuses on 1-2 key interpersonal issues most
closely related to the depression.
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Interpersonal events include:
– interpersonal disputes / conflicts
– interpersonal role transitions
– complicated grief
MH interventions with little or NO
evidence of effectiveness for Depression:
Family Therapy*
 Relaxation
 Self-Control Training
 Self-Modeling
 Non-directive Supportive Therapy
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* note: Family Engagement in CBT and IPT,
however, has been shown to be important!
Practice Elements for Depression
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Child Psychoeducation
Cognitive/Coping
Problem Solving
Activity Scheduling
Skill-building/Behavioral
Rehearsal
Social Skills Training
Communication Skills
Parent Psychoeducation