Transcript - Eden Health Care Services

ANXIETY AND DEPRESSION
IN YOUTH
Andrew Hall, MD, FRCP
Child & Adolescent Psychiatrist
MATC
All Truth is God’s Truth
Arthur Holmes
(St. Augustine)
Nobody ever sees truth
except in fragments
Henry Ward Beecher
Recognizing mental health
disorders in Children &
Adolescents can be difficult
because they are experiencing so
many changes already.

Changes in Behavior

Changes in Feelings

Changes in Physical Health

Changes in Thinking
Facts about Anxiety:

Anxiety Disorders are among the most common mental
health problems to occur.

About 15 of every 100 children and adolescents ages 9 to
17 experience some kind of Anxiety Disorder.


Girls are affected more than boys. About 50% of children
and adolescents with anxiety disorders have a 2nd anxiety
disorder or other mental/behavioral disorder.
Anxiety Disorders may coexist with physical health
conditions as well.
Why is this so important?
Children & Adolescents


Median age of onset 11 – earliest of all forms of
psychopathology
20% will have an Anxiety Disorder between the
ages of 13 and 18

5.9% will have “severe” Anxiety Disorder

Only 18% of these teens receive treatment.
Fear, Anxiety, and Stress



Anxiety: Future-oriented worry of the
unknown.
Fear: Present-oriented defensive response
to observable threat.
Stress: Perceived environmental demands
exceed one’s perceived ability to meet
them.
3 Pillars of Anxiety
1.
Fear of the unknown
2.
Lack of control
3.
Perception of danger
Brief Definitions



Anxiety is a general feeling of apprehension or
worry and is a normal reaction to stressful
situations
Red flags should go up when the feelings
become excessive, thoughts become irrational
and everyday functioning is debilitated.
Anxiety Disorders are characterized by
excessive feelings of panic, fear or irrational
discomfort in everyday situations.
When does Anxiety become disordered?

Distress

Avoidance

Interference

Functional Impairment
How Anxiety is Manifested

Youth may feel a sense of dread

Have fears of impending doom

Experience a sense of suffocation

Anticipation of unarticulated catastrophe

Loss of control over their breath, swallowing, speech, and
coordination

Somatic complaints
What causes Anxiety Disorders?

Multiple, complex origins

Genetics

Stress Reactions (acute or chronic)

Learned Behavior (implicit or explicit)

Developmental factors
Childhood Fears and Worries
AGE
FEARS
0-6 months
Loss of support, loud noises
7-12 months
Fear of strangers; fear of sudden, unexpected, and looming
objects
3 years
Masks, dark, animals, separation from parents
4 years
Parent separation, animals, dark, noises (including at night)
5 years
Animals, “bad” people, dark, separation from parents, bodily harm
6 years
Supernatural beings (e.g. ghosts, witches, ghouls), bodily injuries,
thunder and lightening, dark, sleeping or staying alone, separation
from parent
7-8 years
Supernatural beings, dark, fears based on media events, staying
alone, bodily injury
9-11 years
Tests and examinations in school, school performance, bodily
injury, physical appearance, thunder and lightening, death, dark
(low percentage)
Effects of Anxiety






School Failure
Absenteeism
Classroom disruption
The inability to complete basic tasks
Family Stress
Impaired Social Relationships
Type of Anxiety Disorders

Generalized
Anxiety Disorder
(GAD)
GAD results in
students
experiencing six
months or more of
persistent,
irrational and
extreme worry,
causing insomnia,
headaches and
irritability.

Post Traumatic Stress
Disorder (PTSD)
PTSD can follow an exposure to
a traumatic event such as
natural disasters, sexual or
physical assaults, or the
death of a loved one. Three
main symptoms: reliving of
the traumatic event,
avoidance behaviors and
emotional numbing, and
physiological arousal such as
difficulty sleeping, irritability
or poor concentration.
Panic Disorders:
Characterized by unpredictable panic attacks, which
are episode of intense fear, physiological arousal, and
escape behaviors. Common symptoms: heart
palpitations, shortness of breath, dizziness and anxiety
and these symptoms are often confused with those of
a heart attack.
Specific Phobias:
Intense fear reaction to a specific object or situation
(such as spiders, dogs, or heights) which often leads to
avoidance behavior. The level of fear is usually
inappropriate to the situation and is recognized by the
suffered as being irrational.
Disorders continued…
Social Phobia
Extreme anxiety about being judged by others or behaving in a way that
might cause embarrassment or ridicule and may lead to avoidance
behavior.
Separation Anxiety Disorder
Intense anxiety associated with being away from caregivers, results in
youths clinging to parents or refusing to do daily activities such as
going to school.
Obsessive Compulsive Disorder (OCD)
Students ay be plagued by persistent, recurring thoughts (obsessions) and
engage in compulsive ritualistic behaviors in order to reduce the
anxiety associated with these obsessions (e.g. constant hand washing).
Treatment Works!


Treatment success rates for Anxiety
Disorders with CBT range from 60% to 90%.
Frequency, Intensity, Duration
Basic template for the Treatment of
Anxiety Disorders in Youth
Assessment
 Psychoeducation
Cognitive Reappraisal Strategies
 Exposure
 Parent Training
 Relapse Prevention


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
problem solving skills to reduce feelings of
hopelessness.
The Cognitive Triangle
Relaxation Strategies
Deep Breathing
 Inhale for count of 5 and hold briefly
 Exhale for count of 5
 Repeat 5 times
Progressive Muscle Relaxation
• Begin with feet, contract muscles for count of 5 and
slowly release.
• Move up the body through all muscles groups
Things I can do to relax when upset
(Identify ones that work for the youth)









Running
Weight Lifting
Going for a walk
Playing a sport
Listening to music
Dancing
Read
Do a puzzle
Crafts





Call a friend
Talk to someone
Take a hot shower
Imagine a relaxing
place in my mind
Deep slow
breathing
Check list of Cognitive Distortions:
1. All or Nothing thinking: You look at things in absolute, black-and-white
categories
2. Overgeneralization: You view a negative event as a never-ending pattern
of defeat.
3. Mental filter: You dwell on the negatives.
4. Discounting the positives: You insist that your accomplishments or
positive qualities don’t count.
5. Jumping to Conclusions:
a: mind reading – you assume that people are reacting negatively to you
when there’s no definite evidence
b: fortune-telling – you arbitrarily predict that things will turn out badly.
Cognitive Distortions continued…
6. Magnification or minimization: You blow things way of of
proportion or you shrink their importance.
7. Emotional Reasoning: You reason from how you feel: “I feel like an
idiot, so I must really be one”.
8. “Should Statements”: you criticize yourself (or other people) with
“shoulds”, “oughts”, “musts” and “have to’s.”
9. Labeling: Instead of saying “ I made a mistake,” you tell yourself,
“I’m a jerk,” or “a fool”, or “a loser”.
10. Personalization and blame: You blame yourself for something you
weren’t entirely responsible for, or you blame other people and
deny your role in the problem.
Other Considerations

Problem Solving

School Accommodations

Plan for Transitions

Reward and Praise the Youth’s efforts and
successes

Encourage the Youth to participate in
developing interventions.
School Accommodations to assist anxious
youth:








Class participation
Class presentations
Answering questions at
the board
Seating within classroom
Testing conditions
Lunchroom/Recess/unstr
uctured times
Safe person
Cool down pass







Large group
activities/assemblies
Return after time away
Field Trips
Change in routine
Substitute teachers
Fire/Safety drill
Homework Expectations
Medication
When CBT/interventions don’t work…
Medication
Spectrum of Depression

Major Depression Disorder

Dysthymia

Adjustment Disorder with Depression

Adjustment Disorder with Mixed Anxiety and Depressed
Mood


Bipolar Disorder

Substance – Induced Mood Disorder
Depression

2.5% children (M:F 1:1)

8.3% adolescents (M:F 1:2)

40-80% experience suicidal thoughts

35% of depressed youth will attempt suicide

Affects every facet of life – peers, family,
school and general health.
How Depressive Symptoms manifest?
Mood
 Depressed or irritable mood
 Mood Lability
Behavior
 Kids may not verbalize sadness but show low frustration
tolerance, social withdrawal or somatic complaints
 Decreased interest (stop sports etc.)
How Depressive Symptoms manifest
continued…
Vegetative Symptoms
 Fatigue or decreased energy
 Sleep disturbance (often hypersomnia)
 Weight change, appetite change
 Decreased concentration or indecisiveness
Cognition
 Feelings of worthless/hopeless or inappropriate guilt
 Thoughts of death or suicide
Criteria for Major Depressive Episode:
Depressed mood or anhedonia + 4 others
S – sleep, insomnia or hypersomnia
I – interests
G – guilt, feeling worthless or hopeless
E - energy
C - concentration
A - appetite
P – psychomotor retardation or agitation
S – suicidal thoughts or recurrent thoughts of death
Symptom variation based on age



At all ages – depressed mood, “I don’t care”, bored,
decreased concentration, insomnia and + SI
Children: >somatic complaints, separation anxiety,
phobias , sad affect, auditory hallucinations
Teens: >anhedonia, hopelessness, drug abuse/self
destructive behavior or atypical depression pattern

Increased sleep, increased appetite and interpersonal
rejection sensitivity
Depression in Youth: timing of presentation

Susceptibility of developing brain

Sleep disturbances

Hormonal changes

Psychosocial pressures
Gathering History

Best to interview both parents and youth

Parents better at reporting behavioral
disturbances and time course of symptoms

Youth better at reporting on
mood/anxiety/sleep

Youth often have depressed mood or SI that
parent is unaware of
Gathering History






R/O neglect, abuse physical or sexual
Recent stressors
Anxiety symptoms
Unusual thoughts or psychotic symptoms
prodrome to Schizophrenia
Symptoms of mania now or past – decreased
need for sleep, hypersexuality or
grandiosity
FHx of suicides or Bipolar Disorder
Genetics




Depression runs in families
Monozygotic twin 76% concordance; and if
raised separately 67% concordance
Children with one depressed parent are 3x
more likely to have MDD than children of
non-depressed parents
Need to ask about family history of Bipolar
Disorder or any Mood Disorder
Effects of depressed parents



Depression in parents associated with child
depression (mothers>fathers).
Depressed children tend to have poor
relationships (family and friends) & often have
depressed parents.
Depressed parents may over-report concerns
(focus on negative aspects) or under-report
(too depressed to attend to or observe child
accurately.
Differential
Infectious




Mononucleosis
TB
Hepatitis
Subacute
endocarditis
Neurologic





Epilepsy
CVA
Multiple sclerosis
Post concussive
states
Subarachnoid
hemorrhage
Differential continued…
Endocrine






Diabetes
Cushing’s disease
Addison’s disease
Increase or decrease
thyroid
Increase parathyroid
Decrease pituitary
function
Others




Lupus
Porphyria
Anemia
Etoh or drug abuse
Workup

History

Physical exam

CBC, electrolytes, LFT’s, TSH, UA and B12, vit D

Consider Urine Drug Screen
Course of Major Depression


Median duration of Depression episode is 8
months
70% of pts have a recurrent MDE within 5
years
Course of Major Depression
Prediction of relapse


Early age onset
Increase in number of
previous episodes

Severity
Psychosis

Lack of compliance

Poor prognosis






Increased symptom
severity
Chronicity of Increased
number of relapses
Residual symptoms
Negative cognitive style
or hopelessness
Family problems
Ongoing negative life
events
Sequelae

Depression untreated affects social, emotional,
cognitive and interpersonal skills

Any episode 7-9 months is a long time in a
youth’s life

High risk for nicotine & substance dependence,
early teen pregnancy, physical illness

As adults, higher suicide rates, more medical &
psychiatric hospitalization, more impairment in
work, family and social life.
Treatment

Psychoeducation
 Parents
 School

Individual psychotherapy
 Supportive
 Cognitive
Behavioral Therapy
 Interpersonal Psychotherapy


Family Therapy
Medication
Psychoeducation

All patients should receive
Information about symptoms and typical course
with discussion (depression is an illness; not a sign
of weakness; no one’s fault etc.)
 Discussion of treatment options
 Placing pt in sick role temporarily may be helpful
and temporary school accommodations


No controlled trials with just psychoeducation,
however, many pts improve with only education
and supportive care.
Supportive Treatment

All patients should receive and may be all that
is required for mild depressive sx’s
Meeting frequently to monitor progress
 Active listening and reflection
 Restoration of hope
 Problem solving
 Improving coping skills
 Behavior activation


If not improving in 4 weeks, move to a more
specific treatment
Treatment Options
If has moderate to severe depression, start with more
specific treatment OR if mild to moderate depression not
improving after 4 weeks of supportive care (watchful
waiting):

Individual psychotherapy




Cognitive Behavioral Therapy
Interpersonal Psychotherapy
Family therapy
Medication
Severe Depression – start meds and other referrals
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
problem solving skills to reduce feelings of
hopelessness.
Interpersonal Therapy



Principle of IPT is that interpersonal problems may
cause or exacerbate depression and that
Depressions, in turn, may exacerbate interpersonal
problems.
Treatment will target patients' interpersonal
problems to improve both interpersonal functioning
and his/her mood
Essential elements of ITP include identifying an
interpersonal problem area, improving interpersonal
problem solving skills, and modifying communication
problems.
Medication Treatment Options

Selective Serotonin Reuptake Inhibitors
Selective NE Reuptake Inhibitors
Other antidepressants
Tricyclic Antidepressants

Typical duration of medication treatment



 6-12
months after response present. Relapse
high if stopped within 4 months of symptom
improvement.
Medication - SSRIs






*Fluoxetine (Prozac) – age 8
Sertraline (Zoloft)
Paroxetine (Praxil)
Citalopram (Celexa)
*Escitalopram (Lexapro) – age 12
Fluvoxamine (Luvox)
*FDA approved for the treatment of MDD
under age 18
Medications - SSRIs


Early studies – struggled with high placebo
response rates, had to redesign to screen and have
a waiting period to find subjects that did not
respond to psychoeducation and supportive care
Emslie (1997) – 1st study showing SSRI efficacy
for adolescent depression (fluoxetine)


58% fluoxetine response rate vs. 32% placebo
Emslie (2002) – 2nd study N= 219 pts RCT received
20 mg fluoxetine vs. placebo for 8 weeks

41% remission fluoxetine vs. 20% placebo
SSRIs - dosing

Typically once a day dosing in adults/teens
Morning for fluoxetine & sertraline
 Evening for paroxetine, citalopram & escitalopram



Pre-pubertal children metabolize more quickly –
may need twice daily dosing
Ensure an adequate trial before changing meds,
maximum tolerated dose for at least 4-6
weeks.
SSRIs – Common Side Effects

Nausea and diarrhea – 5HT receptors numerous in gut,
need to titrate slowly, this side effect remits with
exposure.

Headache – usually remits with time

Agitation, impulsivity or activation – 3-8% pts

Insomnia

Fatigue or sedation (more common with paroxetine,
citalopram or escitalopram)
SSRIs – predicting remission



50-60% of patients get response with 1st
SSRI
30% of patients get into remission with 1st
medication trial
Predictors of remission include
 +FHx
of depression
 Early symptom response (within 4 weeks)
Treatment of Adolescents with
Depression (TADS)


Follow up 5 years later N=196 pts (44.6% of
original cohort)
By 2 years, 96.4% had achieved recovery
 Predicted

by early response to meds
By 5 years, 46.6% a recurrence
Medication Summary

Most evidence for SSRIs

Meds considered first line




Fluoxetine (Prozac)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)

Treat for 6-9 months once symptoms have improved

Goal to treat to remission (no sx’s for >2 months)
Suicide

CDC – 17% of adolescents think about suicide each
year

Thoughts of death are part of MDD

3rd leading cause of death in adolescents about
2,000 deaths per year

25% decline in suicide rate in 10-19 year range in
past decade

Suicide attempts often impulsive in nature
FDA warning about +SI and
antidepressant meds

FDA reviewed 23 studies with 9 different meds >4,300 youth

NO SUICIDES in these studies


Adverse events reporting – SI or potentially
dangerous behavior reported by 4% of pts on meds
vs. 2% on placebo
17 of 23 studies asked about SI – no new SI or
worsening of SI, actually decreased during
treatment
Suicide and SSRIs

FDA changed black box warning from specific
monitoring to more general one
All patients being treated with antidepressants
for any indication should be monitored
appropriately and observed closely for clinical
worsening, suicidality, and unusual changes in
behavior, especially during the initial few
months of a course of drug therapy, or at
times of dose changes, either increase or
decreases.
General advice for families regarding SI







No firearms in home
Limit access to medication including over the
counter meds
Remove access to parent’s medications
Remove razors from bathroom or other sharps
Increase supervision (e.g. keep doors open, limit
peer contact to with adults present)
Importance of seeking help if suicidal thoughts
develop or worsen
Mobile Crisis team, Children’s Hospital E.R. and
911

The ABCs of Mental Health

Teen Mental Health

Canadian Mental Health

Kidshealth.org

Keltymentalhealth.ca

StressHacks.ca
Thank you!
Questions?