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