Transcript Depression in Children and Adolescents

The WPA Educational
Program on the Management
of Depressive Disorders
Depression in Children and Adolescents
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Continuum of Depression
Depressive disorders exist on a continuum and are
classified on the basis of age, severity, pervasiveness, and
presence or absence of mania.
At the mildest end of the spectrum are Adjustment
Disorders with Depressed Mood. Dysthymic disorders are
the second category, and Major Depression is the most
severe condition.
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Follow-up Studies
Development is the process by which traits are maintained through the
relationship between a child and his/her experiences. (Sameroff, 1985;
2003)
Childhood depression is more associated with psychosocial adversity
and is not a precursor of adult depression.
Adolescent onset depression is more often an early onset of adult
depression and seems to be more genetic-dependent than
environment-dependent (as opposed to childhood-onset depression)
(Harrington et al 1996)
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Epidemiology(1)
Prevalence
• Infants 0.5-3%
• Prepubertal children 1-2%
• Adolescents 3-8%
• Adolescent onset is associated with a strong risk for
reoccurrence in adulthood
• The gender difference in prevalence first appears in
adolescence
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Epidemiology(2)
Gender
Until puberty, girls are not more prone to depression than boys.
Increases in depressive symptomatology in girls begin to be
detected at age 12 and are observable at the diagnostic level by
the age of 13 and older
(Angold et al, 2006).
Gender differences are possibly due to biological, psychosocial
and cognitive factors
(Orvaschel et al, 1997).
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Etiology (1)
Gene-environment interaction
Genetics
• Family studies have shown a two to fourfold increased risk of depression in
first-degree relatives (Kovacs & Devlin, 1998; Weissman et al, 2005).
• Adoption studies show some evidence of a genetic effect on the transmission
of major depression (Wender et al, 1986).
• Twin studies show that depressive symptoms have a greater concordance
among monozygotic than zygotic twins (McGuffin et al, 1991).
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Etiology (2)
Environmental risk factors
• Exposure to traumatic circumstances, like war, car accident, nature disaster,
etc.
• Death of a close person
• Relocation of family
• Divorce of parents
• Living in an abusive family where children regularly witness, or are victims of
parental aggression, rejection, or scapegoating.
• Strict and punitive treatment by parents
• Severe parental psychopathology
• Chronic or life threatening illness
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Etiology (3)
Neurobiological factors
• Serotonergic system - lower whole-blood serotonin
• Neuroendocrine system – changes in cortisol, DST, CRH, GH, TSH
• Sleep - shorter REM latency, REM density differences and less sleep efficacy
was found in adolescents
• Neuroimaging - smaller PFC and amygdala, and larger third and fourth
ventricles of depressed young adults and adolescents
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Clinical Manifestations (1)
Signs and Symptoms among preschool children
A modified DSM criteria was found to be more sensitive for use with infants and
preschool children (Lubi et al, 2003).
The 2 weeks duration criteria was put aside
• Sad/grouchy mood
• Anhedonia
• Appetite and weight problems
• Sleep problems
• Change in activity level, low energy
• Low self esteem
• Trouble thinking/ concentrating
• Death or suicide themes in play/talk
• Whines/cries
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Clinical Manifestations (2)
Signs and symptoms among children
• Boredom
• Lost interest or pleasure in most activities
• Complaints about being tired most of the time or lack the energy to engage in
normal activities
• Irritability and moody- swinging from great sadness to sudden anger temper
tantrums
• Lack of satisfaction
• School absence and avoidance of social activities
• Physical symptoms with no medical explanation
Restlessness, agitation, and decreased concentration may mislead parents or
teachers into thinking that a child has attention deficit disorder
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Clinical Manifestations (3)
Signs and symptoms among adolescents
• Sad mood or if life and future seems grim and bleak,
• Withdrawn, uncharacteristically lacks energy and initiative
• Neglected appearance
• Slow movements and monotonous voice
• Heightened sensitivity to rejection by others
• Low self esteem
• Poor concentration, deterioration in school grades
• Loss of interest in extracurricular activities
• Sleeping throughout the day or early in the evening
• Complaints of headaches or stomachaches
• Use drugs or alcohol, in some cases as self-medication
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Clinical Classification (1)
Diagnostic and Classification Manuals
• DC 0-3 R a modification of the DSM-IV-R for children under 3 years of age
• Modified DSM-IV for preschool children
• DSM-V and ICD-10 for older children and adolescents
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Diagnostic Assessment (1)
• Diagnosis of depression is difficult to assess accurately, especially among
young children
• The child is the best source of subjective symptoms
• It is important to use parental reports, yet reports may be inaccurate or biased,
especially among depressed parents
• Another avenue to evaluate depression among children is by observing play,
either dyadic or triadic in the younger ones, or individual play in the older ones
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Diagnostic Assessment (2)
Structured assessment tools
• Child Behavior Checklist (Achenbach & Edelbrock, 1983)
• Self-report questionnaires such as the Children’s Depression
Inventory (Kovacs, 1981)
• Schedule for Affective Disorders and Schizophrenia for School-Age
Children (K-SADS; Chambers & Puig-Antich, 1987)
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Comorbidity (1)
Physical illness
• Poor physical health predicted an increased risk of future depression and a
diagnosis of major depression predicted an increased risk of future poor
physical health (Cohen et al, 1998; Lewinsohn et al, 1996).
• Depressive symptoms can accompany conditions such as cancer,
hyperthyroidism, hypothyroidism, lupus erythematosus, acquired immune
deficiency syndrome, anemia, diabetes, epilepsy.
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Comorbidity (2)
Physical illness
• Interview-based studies suggest that 5%–23% of ill children and adolescents
met criteria for major depression (Burke & Elliot, 1998).
• Children suffering from conditions directly involving the central nervous system
showed higher rates of psychiatric disorders (Melzer et al, 2000).
• Chronic illness such as severe asthma, inflammatory bowel disease and
diabetes sickle cell disease were found to have higher rates of depression
(Burke & Elliot, 1998; Bennet, 1994).
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Comorbidity (3)
Attention Deficit/Hyperactivity Disorder
• 0%-57.1% of children and adolescents with depression also met criteria for
ADHD (Angold and Costello, 1993).
• Comorbidity of ADHD was found among 30% of children and 15% of
depressed adolescents (Masi et al, 1998).
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Comorbidity (4)
Conduct Disorder
• 22.7%-83.3% of children and adolescents with depression also met criteria for
ODD or CD, whereas 8.5%-45.4% of those with ODD or CD also met criteria
for depression (Angold and Costello, 1993).
• Longitudinally, youth with both conduct problems and depression are also
prone to increased long term problems in functioning compared with
depressed only youth (Harrington et al, 1991; Kovacs et al, 1988).
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Comorbidity (5)
Obsessive Compulsive Disorder
• No large scale study was conducted about the proportion of comorbid
obsessive compulsive disorder (OCD).
• In a study of 68 children with a first episode of major depressive disorder 24%
of children had comorbid OCD at presentation.
• Having comorbid OCD at presentation was a risk factor for persistent
depression at 72 weeks follow-up
(Goodyer et al, 2001).
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Treatment Modalities (1)
When to refer a child to a mental health professional
• Collect parental report of symptoms and behavioral changes, as well as
duration of symptoms and any possible precipitating event
• Guide parents and professional (pediatrician, family doctor, school teacher or
school counselor) to talk to the child and show interest and the desire to help
and understand the child's feelings.
• Try to determine whether the child seems capable of handling the feelings, or
whether the child is overwhelmed by the feelings, and his daily functioning is
impaired.
• Rule out underlying physical disease or illness that could also produce
depressive symptoms.
• If symptoms persist, particularly if they are dangerous or seriously interfere with
the child's life, child's physician should make a referral to a child and adolescent
psychiatrist or other mental health professional experienced in working with
children.
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Treatment Modalities (2)
Pharmacotherapy
The use of antidepressants in children and adolescents is still a controversy
due to the warnings which have been published by the FDA on negative
results and increased risk of suicidal ideation behavior and attempts with
SSRI treatment . Nevertheless, the last document of Practice Parameters
published by the AACAP in Nov. 2007 gives different conclusions:
• The use of SSRI in Pediatric Depression resulted in a reduction of
Adolescents suicide.
• The rate of improvement with SSRI is 40-70%, as compared to placebo
(30-60%), the real difference being mainly in adolescence.
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CTD
• Although Venlafaxine and Fluoxetine showed a statistically significant
association with suicidality, there have been only few suicidal attempts, and
no completion. 11 times more depressed patients may respond favorably to
anti depressants than may spontaneously report suicidality. The relationship
is not a causality one.
• The risk/benefit ratio for SSRI use in Pediatric depression appears to be
favorable with careful monitoring.
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CTD
• Close monitoring of treated children and adolescents includes the
assessment of symptoms such as irritability, hostility, self-harm ,selfdestructive actions, akathisia, withdrawal effects, sleep disturbances,
increased agitation, and induction of Mania.
• Adolescents more than children seem to benefit from antidepressants
treatment.
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Treatment Modalities (3)
• To date, Fluoxetine is the only antidepressant with proven favorable risk/benefit
profile for the treatment of depression in children and adolescents. The
risk/benefit profile is unfavorable for paroxetine, venlafaxine, sertraline,
citalopram, escitalopram and mirtazapine
• Increased suicidal ideation with any SSRI must be considered
• TCA - No evidence of significant efficacy for and therefore are not standard
treatment for depression in children
• Electroconvulsive therapy is an effective treatment that can be used in
adolescents
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Treatment Modalities (4)
• Drug metabolism is age-dependent. Thus, doses and frequency of
administration need to be adjusted when prescribed for children and
adolescents .
• Some studies have reported that half lives of Sertraline, Citalopram and
Proxetine, are shorter in children.
• We should start with low dose for 4 weeks and than increase if necessary. We
should get remission after 12 weeks.
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Treatment Modalities (5)
Psychotherapy
Infant-parent psychotherapy
Joint work with parents and infants under 3 years old, with the
ultimate goal of improving parent-infant relationships and the child's
socioemotional functioning.
Play therapy
Through a combination of talk and play the child has an opportunity
to better understand and manage their conflicts, feelings, and
behavior.
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Treatment Modalities (6)
Psychotherapy
Parental guidance
Education of the child and the family about the disorder and its treatment
allows proceeding with less parental self blame, and blame of the child.
Individual psychodynamic psychotherapy
Understanding the issues that motivate and influence a child's behavior,
thoughts, and feelings, and help identify a child's typical behavior patterns,
defenses, and responses to inner conflicts and struggles.
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Treatment
Psychotherapy
Cognitive behavioral therapy (CBT)
Techniques for youth depression that targets cognitive distortions and
behavioral deficits and teaches specific mood regulation skills through
encouraging practicing.
Interpersonal therapy (ITP)
The most recently developed psychotherapeutic intervention for adolescents. It
is a manualized treatment, limited in time, that focuses largely on current
interpersonal issues, and how depression and relationship affect one another.
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Treatment
• Treatment should include the management of comorbid conditions. One has
to evaluate which condition is causing the greatest distress and functional
impairment and begin treatment with it.
• Arrange frequent follow up sessions for optimal monitoring.
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