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Depressive Disorders in Children and Adolescents: Identification and Treatment. Elizabeth McCauley, PHD, ABPP Professor University of Washington/Seattle Children ’ s Hospital. Agenda. What is Depression? Scope of the Problem Diagnostic Dilemmas - PowerPoint PPT Presentation
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Depressive Disorders in Children and Adolescents: Identification
and Treatment
Elizabeth McCauley, PHD, ABPP
Professor
University of Washington/Seattle Children’s Hospital
Agenda
• What is Depression?• Scope of the Problem• Diagnostic Dilemmas• Causal Model: predisposing, precipitating, perpetuating• Adolescence as a Risk Factor• Assessment• Treatment
What is Depression??
• Major Depressive Disorder• Depressed Mood/Irritability and/or anhedonia• Presence of subset of other symptoms: sleep or appetite disturbance,
morbid ideation/suicidality, decreased energy, difficulties concentrating/making decisions, hopelessness/down on self
• Symptoms which occur together, persist for at least two weeks and are associated with a significant loss of ability to function
• Other depressive dxs: Dysthymia, Adjustment Disorder with Depressed Mood
• Mounting body of evidence suggest that depression differs from normal experience in degree, rather than in type (Coyne, 1994; Ruscio & Ruscio,2000, 2002). • Major depression appears to be a quantitative variation of normal functioning• Use of continuous versus categorical assessment approaches
What is Depression??
When is depression depression….? Persistent vs. transient symptoms—79% persistence in recent
study of 8th graders assessed via self-report in a school setting at 4 week intervals
Youth with subclinical symptoms at increased risk for subsequent depression, adverse outcomes
Experiencing a first episode of depression increases the likelihood of recurrence and continuation into adult life
Importance of assessing functional impairment
Depression: Scope of the Problem
• Children: 1 year prevalence rate of 2%
• Adolescents: 1 year prevalence rate of 4% to 8%
• National Cormorbidity Survey: 6.1%, 15-24 years
• Lifetime prevalence (up to age 18) 15%-20%
• 65% of adolescents report some depressive symptoms
• 5% to 10% of youth with subsyndromal symptoms have considerable psychosocial impairment, high family loading for depression, and an increased risk for suicide and developing MDD (Fergusson et al., 2005)
Scope of the Problem
• Mean length of episodes: 7 to 9 months
• 6% to 10% become protracted
• Recurrence: 30 -50%
• Approximately 20% develop bipolar disorder
• Associated with significant:• comorbidity• functional impairment • risk for suicide• substance use
Diagnostic Dilemmas: Comorbidity
Depression 40% to 90% have co-morbid dx; 50% 2+
-- Dysthymia and anxiety – 30% to 80%-- Disruptive Disorders – 10% to 80%-- Substance Abuse – 20% to 30%
Community-based study--43% of depressed youth had at least one other concurrent diagnosis, most commonly anxiety (18%). (Rhode, et al., 1994)
MDD presents after anxiety and disruptive dx: substance abuse 2nd to depression
Odds Ratios--Anx 8.2; Conduct and ODD 6.6; ADHD 5.5 times more common in depressed youth
Causal Model?
Stress Diathesis ModelDiathesis—vulnerability
Biological—genetic, temperament STRESS GENE ?? Environment—loss, abuse, neglect,
demoralization Cognitive Style—negative cognitive
style, see cup ½ empty, attribute failure to internal characteristics, success to chance, hopelessness
Increasing Prevalence of Depression in Adolescence
Depressive Disorders:• Adults: 15-20% rates; 2:1 female to male• Age 11: Incidence low; males > females• Age 13: Incidence rising; males = females• Age 15, 18, 21: Incidence rising; males <
females
Adolescent Development
Development of overall rates of clinical depression (1-year point prevalence combining new cases and recurrences by age and gender)
(Hankin, et al., 1998)
Why are Adolescents So Vulnerable?
Neurobehavioral Development in Adolescents
Early AdolescencePuberty stimulates changes in brain systems regulating arousal and appetite that
influence intensity of emotion and motivation
Late AdolescenceWith age and experience
comes maturation of frontal lobes which
facilitates regulatory competence
Middle Adolescence adolescent emotional and behavioral
problems 2nd to poor regulation skills--particularly when gap between pubertal arousal and consolidation of
cognitive skills is extended
Case Presentations
• 14 year old male, first semester of high school, bout of the flu—never back to school on a regular basis,
• Stressors: Significant growth spurt in 7-8th grade, move from family home, start of high school, loss of cat, family discord
• Presentation: Inability to attend school, irritability, appearance of depressed mood, loss of interest in activities, social withdrawal, marked sleep disturbance, dec concentration
Case Presentations
• 10 yr old girl with history of marked irritability and tendency to see “cup half empty”
• 13 year old Chinese Am girl, sudden drop in grades with acute onset depressive sx
• 17 yr old female, senior in high school, high achieving, family conflict, struggling to emancipate
• 16 yr old boy, junior in high school, active in scouts, threatens peer at school, parental illness
Importance of Assessment
•Assessment before making treatment plan•Assessment of changes in key symptoms/ behaviors during tx•Assessment of how things are going from family/youth’s persepctive
Assessment Tools
Why Use: Raise adolescent’s awareness of issue as a
possible concern Let adolescent know these issues can be
brought up Allow opening for educational intervention Demonstrate concern
Depression Screening Scales
Patient Health Questionnaire for Adolescents (PHQ-A) 5 minutes to complete, easy to score algorithms based
on DSM-IV criteria for Major Depressive Disorder and Dysthymia
Algorithms for mental health comorbidities that might be seen in primary care (Generalized Anxiety Disorder, Panic Disorder, Substance Abuse or Dependence, Alcohol Abuse or Dependence, Nicotine Dependence, and Eating Disorders).
Children’s Depression Rating Scale (27) Measures distress; clinical cut-off 20
Depression Screening Scales
Beck Depression Inventory for Primary Care (BDI-PC) is a 9-item self-report measure of depressive symptoms,
The primary care version has been shown to have high internal consistency, good concurrent validity in adolescent samples
Moods and Feelings Questionnaire (30) Brief format—13; 11/8 clinical cut-off
Achenbach Youth Self-Report Form (103+) Assesses social function, mood, anxiety, and behavioral
problems
www.ASEBA.org
Moods and Feelings (Angold et al., 1995)
• I felt miserable or unhappy • I didn't enjoy anything at all • I felt so tired I just sat around and did nothing • I was very restless • I felt I was no good anymore • I cried a lot • I found it hard to think properly or concentrate • I hated myself • I felt I was a bad person • I felt lonely • I thought nobody really loved me • I thought I would never be as good as other kids • I did everything wrong
0-2 scale. clinical cutoff 11
Patient Health Questionnaire (PHQ-9)
• Little interest or pleasure in doing things• Feeling down, depressed, or hopeless• Trouble falling/staying asleep, sleeping too much• Feeling tired or having little energy• Poor appetite or overeating• Feeling bad about yourself – or that you are a failure or have let yourself or
your family down • Trouble concentrating on things, such as reading the newspaper, watching
TV• Moving or speaking so slowly that other people could have noticed. Or the
opposite – being so fidgety or restless that you have been moving around a lot more than usual
• Thoughts that you would be better off dead or of hurting yourself in some way
0-3 scale. Not at all to Nearly Every Day; 10-14 Moderate Dep
Assessment: Depression
• Sorting out parent/youth conceptualization of the problem• Parent/youth’s sense of what treatment will be useful• Differential trajectories—hopelessness depression, age of
onset, ADHD or other co-morbidities• Acute family problems--parental mental health concerns,
abuse/neglect, derogation, reinforcement for illness behavior, cultural/generational conflicts, unresolved grief
• School Issues--learning disability, attendance problems, harassment, isolation
• Peer/partner issues--pregnancy, sexual pressure, break-ups, sexual orientation issues, loss of friends
Assessment and Case Conceptualization
•Assessment before making treatment plan
•Assessment of changes in key symptoms/ behaviors during tx
•Ongoing assessment of issues to refine your case conceptualization
Case conceptualization Tx Choice
•Anxiety Disorders• Kendall’s Coping Cat;
March’s OCD Tx• Social Effective Tx-
Beidel• Exposure/Transfer of
Control-Silverman•Depression
• CBT—Clarke, Lewinsohn
• Interpersonal Psychotherapy--Mufson
• Behavioral Activation
•ADHD• Family, social skills,
attentional skills training
•ODD/CD• Parent-child Interaction
Therapy—Chamberlain• The Incredible Years—
Webster Stratton• Parent/Child Treatment
for Aggression—Barkley, Kazdin
Depression: Treatment Issues
Background and Rationale
Current tx response rates only 60-70% and high relapse within one year
Limitations of pharmacological options Up to 40% are “non-responders” 58-61% report bias against meds (Gray, 2003)
“Medicine might…change my personality, control my thoughts, not let me be myself”
Beliefs about efficacy and stigma Concerns regarding potential increased risk of suicide in youth
using antidepressant medication
Medications Issues
• 3 to 8 fold increase in the use of antidepressants in children and adolescents from approx 1990-2000 (Zito, et al., 2002; Rushton, et al. 2001)
• Efficacy: • Fluoxetine (Prozac) – efficacious • Up to 40% are “non-responders”
• Resistance/Adherence: Adolescent Attitudes (Gray, 2003)• 69% stopped taking meds by end of 4 weeks• 58-61% report bias against meds• “Medicine might…change my personality, control
my thoughts, not let me be myself”• Issues around belief in efficacy of meds and stigma
about MI
Duration of Antidepressant Use
0%
20%
40%
60%
80%
100%
Start 1 2 3 4 5 6
Months after initial prescription fill
SSI
Tricyclic
Other
Richardson, DiGiuseppe, Christakis, McCauley, Katon, 2004.
1998
Psychotherapy for Depression: Evidence of Treatment Effects
Reinecke, Ryan & DuBois
6 CBT Trials
ES = 1.02(0.97)
1999 2002 2006
Lewinsohn & Clarke
12 Trials
ES = 1.27
Michael & Crowley
14 Trials
ES = .72
Weisz, McCarty & Valeri
35 TrialsInc. TADS N=439
IPT- 2 trials
ES = .34(0.40 ULS)*
Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149
* Unweighted least squares
2007
The TADS Team, Arch Gen Psychiatry 2007;64:1132-1143.
Adjusted mean Children's Depression Rating Scale-Revised (CDRS-R) total scores
Moving on with Treatment
CBT-the most widely investigated psychotherapy for depression
Aaron T. Beck
“You can change how you feel by changing how you think”
CBT Draws on 4 core sets of strategies:
• Facilitative• Behavioral Activation• Automatic Thoughts• Core Beliefs
Require ability to reflect on, monitor, and evaluate own thinking process in
midst of heightened emotional arousal—may not have skills on board
Principles of CBT: Philosophy
Collaborative Model Structured Sessions Blend Didactic, Directive, & Socratic
Questioning Ongoing Assessment (inc. regular feedback) Effect Change in Thought, Affect, & Behavior Relapse Prevention
Moving on to Treatment—What Works Best?
Principles of CBT: Technology
Agenda Setting Mood Monitoring Behavioral Activation; Structuring Activities The ABC’s of CBT: Linking Affect, Behavior, &
Cognition Thought Records & Changing Beliefs Cognitive-Behavioral Case Conceptualization Becoming Your Own Therapist
Getting Started:
Assessment, Feedback, & Treatment Plan
Example:
15-year-old girl (Kelly) presenting with depressed affect, loss of interest, sleep and concentration problems, and low self-esteem. Chief complaints are sadness, social isolation, and slipping grades. Maternal history of depression and substance use, absent father, limited family/social support. Endorses suicidal ideation; no plan.
Provide feedback and psychoeducation re: depression and appropriate treatment, discuss role of pharmacotherapy and psychotherapy, establish treatment plan including course of CBT.
Initial Sessions:
Agenda Setting (organize session & model effective strategy)
Mood Monitoring (highlight highs and lows) Activity Scheduling (behavioral activation to
improve mood, increase social exposure) Continue building rapport (validate, praise,
model optimism) Ongoing case conceptualization
Middle Sessions:
The ABC’s of CBT: Linking Affect, Behavior, & Cognition
- What was the situation?- What were you thinking?- How were you feeling?- What did you do?
Thought Records
Thought Record
What happened? How did you f eel?
What thoughts did you have at the time?
What did you do? Any other way to look at it?
List all the emotions you had at the t ime. Did you f eel some more than others?
What does it mean to you that….? So what? What if ?
Did you want to do something you didn’t do? Do something you wish you hadn’t?
Do you f eel diff erently if you think about it this way? Would you do anything diff erently now?
Supplementary Materials…
Middle Sessions:
The ABC’s of CBT: Linking Affect, Behavior, & Cognition
- What was the situation?- What were you thinking?- How were you feeling?- What did you do?
Thought Records Using Thought Records in Ongoing Case
Conceptualization
Middle Sessions:
Cognitive Restructuring:
- Validation
- Downward Arrow
- Evidence Testing
Automatic Thoughts
Underlying Beliefs
Middle Sessions:
Cognitive Restructuring:
- Validation
- Downward Arrow
- Evidence Testing
Using Cognitive Restructuring in Case Conceptualization
Final Sessions:
Relapse Prevention:
‘Becoming Your Own Therapist’
Termination
Core Principles of Interpersonal Psychotherapy
• Link between mood and life events
• Focused, time limited treatment
• “Here and Now” treatment
• Medical Model
• Active Therapist
General IPT techniques
• Supportive listening• Optimistic stance• Encouragement of affect• Eliciting details• Exploring options• Role playing• Communication analysis• Use of the therapeutic relationship
Initial Phase (sessions 1-4)
• Conduct psychiatric interview, assess symptoms, diagnose, offer the sick role
• Conduct Interpersonal Inventory
• Select interpersonal problem area as patient’s treatment focus
• Provide patient with an interpersonal case formulation
Interpersonal Inventory
• Ask about significant people in the adolescent’s life (family, friends, mentors)
• Start with the basics
• Frequency of interactions
• What do they do together?
• Expectations for the relationship
• Were they fulfilled?
• What changes does the adolescent want to make in the relationship
• Has the adolescent tried to make changes already?
• What worked or didn’t work?
• How has depression affected the relationship?
Life Events Associated with the Depression
• Probe for:• Changes in family structure• Changes in school• Moves• Death, illness, accident, or trauma• Onset of sexuality and sexual relationships• Establish a time frame and sequence of events relating to the depression
Common Developmental Issues for Adolescents
Separation from parents
Exploration of authority in relation to parents
Development of dyadic interpersonal relationships with members of the opposite sex
Initial experience with death of a relative or friend
Peer pressure
Interpersonal Problem Areas
Grief
Interpersonal disputes
Role transitions
Single-parent family situations
Interpersonal deficits
Strategies for Treating Interpersonal Disputes
• Focus on the adolescent’s expectations for the relationship• Are they realistic?• How do they differ from expectations of others?• How has teen tried to resolve the dispute?
• Explore communication patterns that may be complicating the resolution of dispute
• Help the teen gain perspective on what has occurred in the relationship
• Help the teen find strategies for coping with unreasonable expectations of the parent and the feelings of anger/sadness engendered
Communication Analysis
• Goal is to teach the adolescent to communicate in a more effective manner through:• Clarity• Directness
• 5 categories of ineffective communication• Ambiguous and/or nonverbal communication instead of
open confrontation• Holding incorrect assumptions• Using unnecessarily indirect verbal communication• Using “the silent treatment” and closing off communication• Using hostile communication
Communication Analysis (II)
Help the adolescent to understand The impact of his/her words on others The feelings he conveys with verbal and nonverbal
communication The feelings that generated the verbal exchange
Teach alternative communication strategies How to communicate feelings and opinions directly Using empathy Understanding the other person’s perspective
--“putting yourself in other person’s shoes”
Treatment Strategies for Role Transitions
• Mourn the loss of the old role and accept the new one or find an alternative role
• Examine the positive and negative aspects of old role, what adolescent is afraid will be lost, and the teen’s perception of new role
• Educate parents about the role transition
• Develop social skills to help teen to successfully negotiate the transition
• Help adolescent generate opportunities to increase social support
Plug for Treatment Development
Peter Lewinsohn
Behavioral Activation“You can change how you feel by changing what you do”Decrease in frequency or range of reinforcing stimuli or increase in frequency of punishment depression
Allows adolescent to practice with “coach” planning,
monitoring and evaluation skills needed to coordinate affect arousal and cognitive skills w/o direct challenge to
beliefs
Focuses 3 core strategies:• Facilitative• Activation • Processes that inhibit activation:
• Withdrawal• Avoidance• Ruminative thinking
Thanks!