Child and Adolescent Depression

Dr. Anahit Gasparyan

Consultant in Child and Adolescent Psychiatry

Wansbeck Hospital

Depression

•Major depressive disorder•Dysthymia• Adjustment disorder with depressed mood

•Within 1 to 3 months, no more 6

• Bipolar disorder• Suicide and self harm

History

• Rufus of Ephesus, Gr. physician,A.D. 2•Melancholia - in adolescents, infants and

young boys•R. Burton- “Anatomy of Melancholy”, 1621

•Education, parenting, inherited

•H. Maudsley,1867 - melancholia - one of the 7 forms of childhood insanity

• Arnold, 1782 - nostalgic insanity in young people

History

• C 18th, Europe - references to affective disorder in children and adolescents

• C 20th - gradual recognition of depression in C&A as nosological category

• Depression as “adolescent turmoil” prior to 1970s and 1980s

• Pre-adolescent - incapable of D.

Major Depressive Episode: DSM-IV

• 5 or >symptoms, 2/52 duration, change from previous functioning

depressed moodloss of interest or pleasureweight/appetite loss/gainsleep disturbancepsychomotor retardation/agitationfatigueworthlessness/guiltlow concentrationsuicidal ideas

Major Depressive Disorder

• Mild

• Moderate

• Severe

• With/without psychosis

• Single/recurrent

• Mixed

Dysthymic Disorder

• Depressed mood for at least 1 year• Presence of 2 or > depressive

symptoms• Never free of symptoms for >than 2

months at a time• Can have distinct episodes of

depression - Double Depression

Adjustment Disorder with Depressed Mood

• Symptoms occur within 1 (ICD-10) to 3 months of stressor

• Distress in excess of expected or

• Impairment in functioning

• Symptoms do not persist for more than 6 months after stressor stops

• Does not meet criteria for other Axis 1

Major Depressive DisorderDSM IV

• Luby and colleagues (2002) proposed modified criteria for C&A depression

• Sad/irritable mood, anhedonia, low energy, eating/sleeping problems, low self-esteem - prominent symptoms

• Depressed/irritable mood must be present not persistent over 2- week

• Persistent death/suicide themes in play for assessment of suicidal ideation

Depressive DisorderICD-10

• Depressed mood, loss of interest and enjoyment, reduced energy- 2x

• Reduced concentration, attention• Reduced self-esteem, self-confidence• Ideas of guilt and unworthiness• Pessimistic view of future• Ideas/acts of s/h or suicide• Sleep problems• Diminished appetite

Problems with Classification

• Depressive symptoms are common in adolescence.

• Depressive disorder should only be diagnosed in:– significant impairment of social functioning– symptoms disabling, causing sign. suffering– severe suicidality present

Aethiology of Early- Onset Depression

• Atypical early epigenesis- first few years

• Leads to formation of vulnerable neuronal network incorporates amygdala and VPC resulting in impaired mood regulation

• Acquired neuroendangerement: reduced synaptic plasticity in hippocampus, NA and ventral tegmentum

Aethiology of Early- Onset Depression.

• Leads to motivational, cognitive , behavioural deficits throughout the life span

• Early depression can be caused by a triadic interplay between trophic, sertonergic and corticoid systems in early development that influence the tonic regulation of HPA axis, amygdala and VPC (Goodyer I, 2008)

Comorbidity

• Conduct disorders- 40% (DSM)

• Anxiety disorders- 34%: GAD and social phobia in A, separation anxiety disorder in C

• Dysthymia-DD, 30-80%

• Substance misuse

Epidemiology and Course

• Children- MDD 2.1%, M=F, 4-5y.o. >2-3

• Adolescents- MDD 4-8%,M:F- 1:2

• Population studies revealed: at any given time 10-15 % of C&A reported depressive symptoms

• By the age of 18- 20-25% - depressive episode

Course

• Worse longitudinal course:– Female sex– Increased guilt– Previous episode of depression– Parental psychopathology

Duration of first episode: children - 8-13/12

Rate of recovery 90%, 30-70% relapses/recurrences

Course

• High rates of recurrence: 20-60% in 1-2 years post-remission

• 70% after 5 years (G. Milavic, 2009)

• In clinical samples average duration MDD episode: 32/52

• DD-up to 3 years (Chrishman, et.al. 2006)

Course

• Duration of first episode in adolescents: 3-9/12

• Rate of recovery: 50-90%• Relapses: 20-54%• Factors predicting greater recurrence:

– Older age of 1 episode– Female sex– Fathers MDD

Course

• Longitudinal predictors of depression/anxiety in 10 year olds:– Lower IQ– Attention/concentration problems– Prenatal marijuana exposure– Household density– Early childhood injuries

Symptoms of Depression

• Low mood (with loss of enjoyment- anhedonia and loss of concentration)

• Biological symptoms (somatic syndrome)• Depressive (negative cognitions) of self,

others and future• Suicidal ideation and acts• Psychomotor retardation/agitation• Delusions of worthlessness, guilt

Depression in Different Age Groups

• In children (prepubescent group):– Withdrawn/inhibited temperament and

irritability are associated with depression– Maternal depression is associated– Less likely to have FHx depression– Genetic factors are less important than in

adolescent depression

Depression in Different Age Groups

• In children (prepubescant group):– Sleep and appetite problems less common– Guilt and hopelessness less common– More somatic complaints (tummy and headaches)– Psychomotor agitation– Separation anxiety/ phobias– Suicidal plans less lethal– Anhedonia- highly specific marker of putative

melancholic subtype

Developmental Caveats in Diagnosing Depression

• Cognitive immaturity– May not be able to verbalise depressive

ideation, express irritability and frustration - temper tantrums

– Emotional immaturity, leading to externalizing distress through behavioral problems(fighting)

Depression in Different Age Groups

• Postpubertal presentation is similar to adult

• Increased risk of suicide in adolescents: ODDs ratio: 11to 27

• Suicide is 3rd leading cause of death in 14-19 year old (Thapar et. al. 2010)

Depression in Different Age Groups

• Substance abuse

• Problematic interpersonal • Relathionships• Documented trend towards generational

increase of depression• Significant continuity into adult life

Clinical Variants

• Psychotic depression

• Bipolar disorder

• Seasonal affective disorder

• Subclinical depression

• Atypical depression

• Treatment resistant depression

Differential Diagnoses

• Normal sadness (grief reaction)• Misery• Non-affective psychiatric disorders:

anxiety disorders, LD, disruptive behavioral disorders (ADHD, ODD)

• Anorexia Nervosa with depressive affect

Differential Diagnoses

• Adjustment disorder with depressed mood

• Chronic fatigue syndrome

• General medical conditions

• Drug and alcohol misuse

Risk Factors

• Gender• Genetic loading• Lower IQ• Early adverse experiences/prenatal exposure• Concurrent psychopathology• Temperament/personality• Negative life events• Family environment/parenting

Risk factors

• Coping/cognitive styles

• Problem-solving skills

• Biological factors

• Household density

• Social isolation

• Ethnicity

Assessment of Depression in C&A

• Caregiver’s/parents’ info• Child’s view, info, story, play, drawing• Collateral info from school,GP, siblings,

other family members• Diagnostic assessments tools (SDQ,

CDI, BDI, PAPA, Dominic Interactive)• Risk assessment (MSE the least)• Non directive play therapy

Treatment

• Psychotherapy– CBT– IPT– Family therapy– Psychodynamic

• Pharmacotherapy

• Psychoeducation

Treatment Guidelines

• NICE, Sept. 2005– Mild D. (5DSM-IV Sx, HAM-D >12-17)- tier

1/2,watchful waiting,psychotherapy– Moderate D.(6DSM-IV Sx, HAM-D >18-

24)- tier 2/3, specific psychotherapy, after -4-6 sessions, add antidepressant

– Severe D. (8DSM-IV Sx, HAM-D >24)- tier 2/3/4 start with psychotherapy and fluoxetine

Medication

• First-line treatment: – SSRI-fluoxetine, in 12-18, in 5-11- cautious

consideration

Second-line:

Sertraline, citalopram

Do not prescribe:

paroxetine, venlafaxine, St.Jon’s wort

Treatment- Children

• Evidence base for medication is only for fluoxetine

• Most of the studies done in adults and youth and extrapolated to children

• Family and environmental changes often could be beneficial

• Contextual Emotion-Regulation Therapy-new, developmentally suitable intervention for children;pilot study; self-regulation of dysphoria

Treatment

• Depression Experience Journal– Computer based intervention for families

with C&A with depression– Psychoeducational therapy based on a

narrative model– Sharing personal stories of depression– Encompasses narrative therapy, social

support, preventive intervention

Treatment

• TADS: CBT no better than placebo• CBT&fluoxetine: beneficial, response rate:-

71%• Fluoxetine only- 61% (Thapar et al. 2010),

acceptable benefit to risk ratio• TCA, venlafaxine, paroxetine- low (Milavic,

2009)• Medication after 4-6/52 of psychological

therapy in moderate/severe MDD

Prognosis

• Mean duration episode MDD 6-9/12

• 70-80% recover by 9/12-12/12

• 10% remain chronically depressed

• Relapse/recurrence- common

• Recurrence -50% within 3-5 years

Prognosis MDD

• Childhood onset– Increased relapses, severity, increased rates of

anxiety– Risk of suicide, bipolar disorder, substance misuse– Better prognosis

• Postpubertal– Risk of suicide, self-harm, substance use, poor

psychosocial functioning in adult life– Boys are at greater risk of persistent depression

Prognosis - Dysthymia

• Persistent course

• High risk of depression (DD), often in about 2 years after initial diagnosis

• Can be difficult to diagnose

• Comorbidity affects the outcome (e.g. conduct disorder)

Deliberate Self-Harm

• Rare in childhood– Boys>girls in <12 year olds

• In adolescents about 100 times more common than suicide– Girls>boys 3:2 community,5:1 clinic– Self-poisoning (OD) most common– Clear precipitant– Depression less likely (adults-40%)

DSH

• 15-25% repeat attempts, 10% within the next year

• 1% will kill themselves within 2 years• Self harm can be cry for help• Thorough assessment of first

presentation is paramount– May help to prevent future attempts

Suicide

• Suicidal ideation is common in adolescence• Completed suicide is more common in men• Surveys in US, CDC, 2000, revealed:

– 8-9% suicide attempt rate– 2-3% - medical help– 27% 17 year olds thought about suicide in 12/12– 16% made plan

Critique

• Comments on NICE by Dr. P.McArdle, 2007• There is no large enough number of RCTs

in C&A population• Role of the clinical experience• The overall evidence of effectiveness is

inconclusive• Complex comorbidities: loss of CBT

superiority > TAU in 6/12