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Mental Health in Adolescents

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Mental Health in Adolescents Mental Health in Adolescents Dr. Nevine Estaphan Dr. Samira Khan Child and Adolescent Psychiatry Fellow Department of Behavioral Medicine and Psychiatry West Virginia University Pediatric Depression Depression in Primary Care • Adolescent depression often identified by PCP’s • shortage of mental health providers • perceived stigma • lack of adequate healthcare coverage • Many feel inadequately trained, supported, and reimbursed • Untreated depression → suicide Epidemiology • Prevalence of depression • 1-3% in prepubertal children • 3-8% in adolescents • However, lifetime prevalence of MDD in adolescents as high as 18% in one study • Adult depression has roots in adolescence • Before puberty -> 1:1 ratio • During adolescence -> 2:1 ratio for girls • 70-80% of adolescents do not receive treatment Risk factors • Genetic predisposition - 1st degree relatives • Parental depression may be a contributing factor • Abuse and neglect • Previous depressive episodes • History of anxiety disorders, ADHD, learning disabilities, and early losses • Family dysfunction or caregiver-child conflict • Peer problems • Academic problems • Negative style of interpreting events or coping with stress • Chronic illness Criteria for Major Depressive Disorder (MDD) • Asterisk symptoms must be present for most of the day nearly every day for at least 2 weeks, with other symptoms present during the same period • Must have 5 (SIGECAPS): • Depressed or irritable mood* • Anhedonia in almost all activities* • Change in appetite/weight • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue/poor energy • Feelings of worthlessness or guilt • Impaired concentration • Recurring thoughts of death or suicide • Persist and cause significant distress or interfere with basic functioning Criteria for Dysthymic Disorder • Symptoms less intense, but more persistent than MDD • Chronically depressed or irritable mood for at least one year plus at least 2 of the following: • Appetite disturbance • Sleep disturbance • Fatigue • Low self esteem • Poor concentration • Difficulty making decisions • Feelings of hopelessness • In adolescents, disobedience and feelings of inadequacy and irritability Course and Comorbidity • Typical major depressive episode is 7-9 months and 90% remit within 2 years • Earlier age of onset → lengthier and more severe course • Median dysthymic episode is 4 years • Relapse is common (40% by 2 years, 70% by 5 years) • 40-70% have comorbid psych disorders • Substance use • Anxiety disorders • Abuse • Disruptive behavior disorders (ADHD, ODD, conduct disorder) • Eating disorders • Learning disorders Differences from Adults • Lack emotional and cognitive ability to identify emotional experiences • Report somatic complaints • Depressed mood inferred from observation instead of patient’s report • Irritable → feel “annoyed” or “bothered”, “unfair” • Negative, argumentative, pick fights • Find others antagonistic or uncaring Differences from Adults • Mood reactivity → cheered up by positive events • Promiscuity, thrill seeking, substance use to temporarily lift mood • Anhedonia → “stupid” or “uninteresting,” pervasive boredom • Withdrawal from social activities • Appetite → failure to make expected weight gain or weight loss • Psychomotor retardation alternating with agitation → restless, pacing, tantrums, hand wringing Differences from Adults • Worthlessness → feelings of inadequacy, inferiority, failure, and worthlessness, “I don’t care”, fear of failure, self-critical • Most do not directly acknowledge such negative self perceptions • Concentration → take longer to complete schoolwork • Thoughts of death → music and literature with morbid themes Evaluation • Difficult due to nonspecific symptoms, comorbidities, and broad differential • Ask questions in a nonstigamatizing and normalizing way • Observe for depressed affect • Diagnosis → clinical interview plus information from caregivers (Essential!) Evaluation • Assess for SI/HI and risk and protective factors • Ask direct questions • Ask about abuse and substance use • Look for comorbidities and possible medical causes • Look for precipitants, stressors, academic, social, and family functioning • Will guide treatment that targets symptoms Evaluation • Recommend referral to specialist for: • Recurrent or chronic depression, esp. if lack of response to initial course of treatment • Complicating psychiatric comorbidities, incl. substance use • Marked functional impairment • Psychosocial factors likely to maintain the depression (i.e. significant family discord) • If diagnosis is unclear • If patient is very guarded • Suicidal ideation or history of suicide attempt • Family unable to monitor safety • Uncomfortable managing pediatric depression Treatment • Requires involvement of the parents/guardians • Psychoeducation is important and should involve the family!! • Decreases likelihood of withdrawal from treatment and reduces stigmatization • Understand depression as an illness • Address psychosocial deficits • Role of medication in treatment • Benefits, risks, side effects • Lag in onset of therapeutic effect • FDA black box warning Psychoeducation • Importance of treatment compliance • Some kids cannot swallow pills • Misunderstandings • Perceived lack of need for treatment • Failure to understand the disorder • Lack of money • Misunderstanding instructions • Complex schedules of drug administration • Limit access to means of self-harm Treatment Studies • Few well designed controlled trials of treatments for adolescent depression • Current practice guidelines based on studies in depressed adolescents, adult depression research, and clinical experience • Much psychopharmacology use is off label for children • Should inform family of this and stay current on literature supporting off label use of drugs Types of Interventions • Psychosocial → understand the nature of depression and manage stressors • CBT, interpersonal, family, dynamic, group, and supportive • Only CBT and interpersonal therapy are evidence based • Pharmacologic → include SSRI’s and others • Combination → superior to monotherapy • Monotherapy with SSRI reasonable in moderate to severe depression if access to CBT may be delayed • ECT → last resort, but effective; can be used in pregnancy Treatment • For nonpsychotic depression, psychotherapy is the first treatment for at least 4-6 weeks • Early onset mood disorders affect development, even after spontaneous remission or successful treatment • Both patients and families benefit from instruction in relapse prevention techniques • Social withdrawal and limited peer relationships may respond to behavioral modification and social skills training • Two major NIMH studies Treatment for Adolescents with Depression Study (TADS) • Evaluated efficacy of treatment with prozac (fluoxetine), CBT, prozac plus CBT, or placebo in adolescents with MDD • Supports short-term combination therapy (CBT plus prozac) • Combination protective against harm-related adverse events • Remission more frequent in the combination group at 12 weeks • At 36 weeks, remission rates in all groups ~ 60% • Recovery earlier in combination therapy and prozac alone • Prozac alone → increased suicide related events • Combination therapy improved functioning, global health, quality of life • Prozac improved only functioning Treatment • If suicidal ideation is present, close supervision and hospitalization may be necessary • Typical response rate to initial monotherapy with psychosocial or pharmacologic interventions is approx 60% with a remission rate between 35- 40% • Pharmacotherapy is generally not sufficient as the sole treatment because of environmental and social problems that often remain after mood has stabilized • Combination treatment increases likelihood of improving family and peer relationships, increasing self esteem, coping skills, and adaptive behaviors Take Home Points • Suicidal ideation is a medical emergency, but emergent administration of antidepressants has no role in the acute management • There are risks associated with any treatment or medication, but also risks related to untreated depression • Untreated depression has the highest risk of morbidity and mortality • Ask about past manic symptoms because 2/3 of bipolar disorders initially present with depression Pediatric Anxiety & OCD Why is this important? • Anxiety is common - whether as a symptom or diagnosis, patient or parent. • Can be disabling • Impacts self-esteem, relationships & academics • Easily misdiagnosed • Many anxiety symptoms are responsive to treatment. • In the US, the cost of mental disorders among persons <24 yo is estimated at $247 billion annually. Representative? Parent Reported Diagnoses - US 2005-2011 Autism, 1.10% Tourette's, 0.20% Depression, 2.10% ADHD, 6.80% ADHD Anxiety, 3.00% ODD/CD Anxiety Depression Autism Tourette's ODD/CD, 3.50% What is anxiety? • There are many varieties of anxiety that affect both children and adults: • Separation Anxiety Disorder • Selective Mutism • Panic Disorder (+/- agoraphobia) • Specific Phobia • Social Anxiety Disorder • Obsessive Compulsive Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder • Generalized Anxiety Disorder • Substance induced anxiety disorder Anxiety • There are yet other disorders that may have symptoms of anxiety as a component of their presentation: • Organic disorders (i.e. cardiac, endocrine, infectious, etc) • Pervasive developmental disorders • Tic disorders • Attachment disorders • Substance use disorders • Mood disorders • Psychotic disorders
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