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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 PhobiaExtreme 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 DisorderIntense 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 evidenceb: 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/
unstructured 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
Mononucleosis TB Hepatitis Subacute
endocarditis
Epilepsy CVA Multiple sclerosis Post concussive
states Subarachnoid
hemorrhage
Infectious Neurologic
Differential continued…
Diabetes Cushing’s disease Addison’s disease Increase or decrease
thyroid Increase parathyroid Decrease pituitary
function
Lupus Porphyria Anemia Etoh or drug abuse
Endocrine Others
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
Early age onset Increase in number of
previous episodes Severity Psychosis Lack of compliance
Increased symptom severity
Chronicity of Increased number of relapses
Residual symptoms Negative cognitive
style or hopelessness Family problems Ongoing negative life
events
Prediction of relapse Poor prognosis
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?