Transcript C&A depression Dr Anahit Gasparyan

Child and Adolescent
Depression
Dr. Anahit Gasparyan
Consultant in Child and
Adolescent Psychiatry
Wansbeck Hospital
Depression
• Major depressive disorder
• Dysthymia
• Adjustment disorder with depressed mood
• Within 1 to 3 months, no more 6
• Bipolar disorder
• Suicide and self harm
History
• Rufus of Ephesus, Gr. physician,A.D. 2
• Melancholia - in adolescents, infants and
young boys
• R. Burton- “Anatomy of Melancholy”, 1621
• Education, parenting, inherited
• H. Maudsley,1867 - melancholia - one of
the 7 forms of childhood insanity
• Arnold, 1782 - nostalgic insanity in young
people
History
• C 18th, Europe - references to affective
disorder in children and adolescents
• C 20th - gradual recognition of
depression in C&A as nosological
category
• Depression as “adolescent turmoil” prior
to 1970s and 1980s
• Pre-adolescent - incapable of D.
Major Depressive Episode:
DSM-IV
• 5 or >symptoms, 2/52 duration, change from
previous functioning
depressed mood
loss of interest or pleasure
weight/appetite loss/gain
sleep disturbance
psychomotor retardation/agitation
fatigue
worthlessness/guilt
low concentration
suicidal ideas
Major Depressive Disorder
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Mild
Moderate
Severe
With/without psychosis
Single/recurrent
Mixed
Dysthymic Disorder
• Depressed mood for at least 1 year
• Presence of 2 or > depressive
symptoms
• Never free of symptoms for >than 2
months at a time
• Can have distinct episodes of
depression - Double Depression
Adjustment Disorder with
Depressed Mood
• Symptoms occur within 1 (ICD-10) to 3
months of stressor
• Distress in excess of expected or
• Impairment in functioning
• Symptoms do not persist for more than
6 months after stressor stops
• Does not meet criteria for other Axis 1
Major Depressive Disorder
DSM IV
• Luby and colleagues (2002) proposed
modified criteria for C&A depression
• Sad/irritable mood, anhedonia, low energy,
eating/sleeping problems, low self-esteem prominent symptoms
• Depressed/irritable mood must be present not
persistent over 2- week
• Persistent death/suicide themes in play for
assessment of suicidal ideation
Depressive Disorder
ICD-10
• Depressed mood, loss of interest and
enjoyment, reduced energy- 2x
• Reduced concentration, attention
• Reduced self-esteem, self-confidence
• Ideas of guilt and unworthiness
• Pessimistic view of future
• Ideas/acts of s/h or suicide
• Sleep problems
• Diminished appetite
Problems with Classification
• Depressive symptoms are common in
adolescence.
• Depressive disorder should only be
diagnosed in:
– significant impairment of social functioning
– symptoms disabling, causing sign. suffering
– severe suicidality present
Aethiology of Early- Onset
Depression
• Atypical early epigenesis- first few years
• Leads to formation of vulnerable
neuronal network incorporates
amygdala and VPC resulting in impaired
mood regulation
• Acquired neuroendangerement:
reduced synaptic plasticity in
hippocampus, NA and ventral
tegmentum
Aethiology of Early- Onset
Depression.
• Leads to motivational, cognitive ,
behavioural deficits throughout the life
span
• Early depression can be caused by a
triadic interplay between trophic,
sertonergic and corticoid systems in
early development that influence the
tonic regulation of HPA axis, amygdala
and VPC (Goodyer I, 2008)
Comorbidity
• Conduct disorders- 40% (DSM)
• Anxiety disorders- 34%: GAD and social
phobia in A, separation anxiety disorder
in C
• Dysthymia-DD, 30-80%
• Substance misuse
Epidemiology and Course
• Children- MDD 2.1%, M=F, 4-5y.o. >2-3
• Adolescents- MDD 4-8%,M:F- 1:2
• Population studies revealed: at any
given time 10-15 % of C&A reported
depressive symptoms
• By the age of 18- 20-25% - depressive
episode
Course
• Worse longitudinal course:
– Female sex
– Increased guilt
– Previous episode of depression
– Parental psychopathology
Duration of first episode: children - 8-13/12
Rate of recovery 90%, 30-70% relapses/recurrences
Course
• High rates of recurrence: 20-60% in 1-2
years post-remission
• 70% after 5 years (G. Milavic, 2009)
• In clinical samples average duration
MDD episode: 32/52
• DD-up to 3 years (Chrishman, et.al.
2006)
Course
• Duration of first episode in adolescents:
3-9/12
• Rate of recovery: 50-90%
• Relapses: 20-54%
• Factors predicting greater recurrence:
– Older age of 1 episode
– Female sex
– Fathers MDD
Course
• Longitudinal predictors of
depression/anxiety in 10 year olds:
– Lower IQ
– Attention/concentration problems
– Prenatal marijuana exposure
– Household density
– Early childhood injuries
Symptoms of Depression
• Low mood (with loss of enjoymentanhedonia and loss of concentration)
• Biological symptoms (somatic syndrome)
• Depressive (negative cognitions) of self,
others and future
• Suicidal ideation and acts
• Psychomotor retardation/agitation
• Delusions of worthlessness, guilt
Depression in Different Age
Groups
• In children (prepubescent group):
– Withdrawn/inhibited temperament and
irritability are associated with depression
– Maternal depression is associated
– Less likely to have FHx depression
– Genetic factors are less important than in
adolescent depression
Depression in Different Age
Groups
• In children (prepubescant group):
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Sleep and appetite problems less common
Guilt and hopelessness less common
More somatic complaints (tummy and headaches)
Psychomotor agitation
Separation anxiety/ phobias
Suicidal plans less lethal
Anhedonia- highly specific marker of putative
melancholic subtype
Developmental Caveats in
Diagnosing Depression
• Cognitive immaturity
– May not be able to verbalise depressive
ideation, express irritability and frustration temper tantrums
– Emotional immaturity, leading to
externalizing distress through behavioral
problems(fighting)
Depression in Different Age
Groups
• Postpubertal presentation is similar to
adult
• Increased risk of suicide in adolescents:
ODDs ratio: 11to 27
• Suicide is 3rd leading cause of death in
14-19 year old (Thapar et. al. 2010)
Depression in Different Age
Groups
• Substance abuse
• Problematic interpersonal
• Relathionships
• Documented trend towards generational
increase of depression
• Significant continuity into adult life
Clinical Variants
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Psychotic depression
Bipolar disorder
Seasonal affective disorder
Subclinical depression
Atypical depression
Treatment resistant depression
Differential Diagnoses
• Normal sadness (grief reaction)
• Misery
• Non-affective psychiatric disorders:
anxiety disorders, LD, disruptive
behavioral disorders (ADHD, ODD)
• Anorexia Nervosa with depressive affect
Differential Diagnoses
• Adjustment disorder with depressed
mood
• Chronic fatigue syndrome
• General medical conditions
• Drug and alcohol misuse
Risk Factors
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Gender
Genetic loading
Lower IQ
Early adverse experiences/prenatal exposure
Concurrent psychopathology
Temperament/personality
Negative life events
Family environment/parenting
Risk factors
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Coping/cognitive styles
Problem-solving skills
Biological factors
Household density
Social isolation
Ethnicity
Assessment of Depression in
C&A
• Caregiver’s/parents’ info
• Child’s view, info, story, play, drawing
• Collateral info from school,GP, siblings,
other family members
• Diagnostic assessments tools (SDQ,
CDI, BDI, PAPA, Dominic Interactive)
• Risk assessment (MSE the least)
• Non directive play therapy
Treatment
• Psychotherapy
– CBT
– IPT
– Family therapy
– Psychodynamic
• Pharmacotherapy
• Psychoeducation
Treatment Guidelines
• NICE, Sept. 2005
– Mild D. (5DSM-IV Sx, HAM-D >12-17)- tier
1/2,watchful waiting,psychotherapy
– Moderate D.(6DSM-IV Sx, HAM-D >1824)- tier 2/3, specific psychotherapy, after 4-6 sessions, add antidepressant
– Severe D. (8DSM-IV Sx, HAM-D >24)- tier
2/3/4 start with psychotherapy and
fluoxetine
Medication
• First-line treatment:
– SSRI-fluoxetine, in 12-18, in 5-11- cautious
consideration
Second-line:
Sertraline, citalopram
Do not prescribe:
paroxetine, venlafaxine, St.Jon’s wort
Treatment- Children
• Evidence base for medication is only for
fluoxetine
• Most of the studies done in adults and youth
and extrapolated to children
• Family and environmental changes often
could be beneficial
• Contextual Emotion-Regulation Therapy-new,
developmentally suitable intervention for
children;pilot study; self-regulation of
dysphoria
Treatment
• Depression Experience Journal
– Computer based intervention for families
with C&A with depression
– Psychoeducational therapy based on a
narrative model
– Sharing personal stories of depression
– Encompasses narrative therapy, social
support, preventive intervention
Treatment
• TADS: CBT no better than placebo
• CBT&fluoxetine: beneficial, response
rate:- 71%
• Fluoxetine only- 61% (Thapar et al.
2010), acceptable benefit to risk ratio
• TCA, venlafaxine, paroxetine- low
(Milavic, 2009)
• Medication after 4-6/52 of psychological
therapy in moderate/severe MDD
Prognosis
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Mean duration episode MDD 6-9/12
70-80% recover by 9/12-12/12
10% remain chronically depressed
Relapse/recurrence- common
Recurrence -50% within 3-5 years
Prognosis MDD
• Childhood onset
– Increased relapses, severity, increased rates of
anxiety
– Risk of suicide, bipolar disorder, substance
misuse
– Better prognosis
• Postpubertal
– Risk of suicide, self-harm, substance use, poor
psychosocial functioning in adult life
– Boys are at greater risk of persistent depression
Prognosis - Dysthymia
• Persistent course
• High risk of depression (DD), often in
about 2 years after initial diagnosis
• Can be difficult to diagnose
• Comorbidity affects the outcome (e.g.
conduct disorder)
Deliberate Self-Harm
• Rare in childhood
– Boys>girls in <12 year olds
• In adolescents about 100 times more
common than suicide
– Girls>boys 3:2 community,5:1 clinic
– Self-poisoning (OD) most common
– Clear precipitant
– Depression less likely (adults-40%)
DSH
• 15-25% repeat attempts, 10% within the
next year
• 1% will kill themselves within 2 years
• Self harm can be cry for help
• Thorough assessment of first
presentation is paramount
– May help to prevent future attempts
Suicide
• Suicidal ideation is common in adolescence
• Completed suicide is more common in men
• Surveys in US, CDC, 2000, revealed:
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8-9% suicide attempt rate
2-3% - medical help
27% 17 year olds thought about suicide in 12/12
16% made plan
Critique
• Comments on NICE by Dr. P.McArdle,
2007
• There is no large enough number of
RCTs in C&A population
• Role of the clinical experience
• The overall evidence of effectiveness is
inconclusive
• Complex comorbidities: loss of CBT
superiority > TAU in 6/12