Depression in Children and Adolescents Ad l Jean A. Frazier, MD Robert M and Shirley S Siff Chair Robert M. and Shirley S. Siff Chair Professor of Psychiatry and Pediatrics Vice Chair and Director, Division of Child and Vi Ch i d Di t Di i i f Child d Adolescent Psychiatry UM UMass Medical School M di l S h l
Disclosure: Jean A Frazier MD Disclosure: Jean A. Frazier, MD Grants/ Research Speakers Company Company Support Support Consultant Consultant Bureau Bureau Other Other Bristol-Myers Squibb X Company Glaxo Smith Kline X Johnson & Johnson Johnson & Johnson X X Neuropharm X Otsuka America Otsuka America X Pharmaceutical Pfizer Inc X
Affective Illness in Youth Introduction I t d ti Major Depressive Disorder : Major Depressive Disorder : Persistent depressed mood and/or irritability for at least 2 weeks and vegetative symptoms f t l t 2 k d t ti t Dysthymia : Persistent depressed mood and/or irritability for at least one year and low self esteem, tiredness, decreased concentration.
Mood Disorders Mood Disorders • Childhood and adolescent depression are real • Mood disorders in children and adolescents are M d di d i hild d d l t among the most common psychiatric disorders • 50% of depressed adults had their first episode before age 20 before age 20 • Life events: stresses play a role in timing and p y g onset
Depression Symptoms in Youth p y p • Frequent sadness that won’t go away, crying Frequent sadness that won t go away, crying • Feeling hopeless, helpless, withdrawn • Change in behavior, loss of interest in usual activities • Change in sleep, appetite or energy g p pp gy • Missed school or poor school performance • Frequent physical complaints F t h i l l i t • Irritability, fighting, trouble concentrating • Thoughts about death, suicide or running away
E id Epidemiology i l P Prevalence: l • MDD- about 2% of children • 5-6% of adolescents • Dysthymia slightly lower prevalence • Dysthymia- slightly lower prevalence Gender distribution: • Pre-pubertal- female/male 1:1 • Adolescent- female/male 2:1 • Adolescent- female/male 2:1
Causes of Depression in Youth Causes of Depression in Youth Biological • Genetics (family history) • Genetics (family history) • Neurochemical Environmental/Psychological Environmental/Psychological • Life Stress
Depression in Pre-pubertal Children Depression in Pre-pubertal Children • Neuro-vegetative signs are also present, although may vary. Appetite less reliable than sleep and energy • Separation anxiety, somatic complaints and p y, p behavior problems (especially aggression) are also common • School failure can be the first manifestation
Depression in Adolescents Depression in Adolescents • Clinical picture may look similar to adult MDD • Suicidal ideation and behavior is a serious risk and must be addressed even in less severe presentations p • Substance abuse, conduct disorder and school failure may also be complications failure may also be complications
Comorbidity: MDD Comorbidity: MDD Hi h l High levels of comorbidity are found in both clinical l f bidit f d i b th li i l and non-clinical samples (Angold and Costello, 1993) •Dysthymia 30-80% y y •Anxiety disorders 40-90% •ADHD/Disruptive Disorders 10-80% ADHD/Di ti Di d 10 80% •Substance Use/Abuse 20-30%
Comorbidity may influence… • severity • duration • relapse risk • increased risk of treatment resistance
Bipolar Risk Factors in Juvenile MDD p • Family history of Bipolar Disorder Family history of Bipolar Disorder • Early onset illness • Psychotic symptoms or psychomotor retardation (Strober et al.) • Pharmacological induced hypomania (Geller et al ) (Geller et al.) • Poor response to antidepressants or mania
Suicide in Youth • 2 nd leading cause of death among college students • 3 rd leading cause of death among 15 – 24 year- olds • 6 th leading cause of death among 5 – 14 year- olds g g y • Nationally, 16% of adolescents consider suicide each year – By the end of high school, over 9% have actually made at least one attempt • Over 5,000 children and adolescent die as a result of suicide each year. Primary methods include: – Firearms (67%) – Hanging (18%) – Overdose (5%)
Suicide Risk Factors • MDD • previous suicidal behavior • positive family history of mood disorder or suicide positive family history of mood disorder or suicide • disruptive behavior disorder • substance abuse disorder b t b di d • psychosocial stressors (loss of parents, family discord) • exposure to family violence • availability to fire arms availability to fire arms • recent rejections and humiliations
Suicide Warning Signs Suicide Warning Signs • Lack of future planning L k f f t l i • Putting affairs in order • Making comments like, “I won’t be a problem for you much longer,” or “You won’t have to worry y g y about me” • Suddenly becoming cheerful after a period of Suddenly becoming cheerful after a period of depression
Childhood Depression Can Be Treated Childhood Depression Can Be Treated • At least 70% - 80% of kids with depression At least 70% 80% of kids with depression can be effectively treated – Without treatment, 40% will have 2 nd episode within 2 p years – 20% - 40% may go on to develop bipolar disorder • Treatment methods may include – Individual psychotherapy – Family therapy – Medication, e.g. TCA’s, SSRI’s • Combined treatment with pharmacotherapy and psychotherapy is recommended
Observations Observations • Suicidal thinking and behavior are common • Suicidal thinking and behavior are common symptoms in depression • Current data suggests that treatment with an C t d t t th t t t t ith SSRI may increase the likelihood that a patient tells someone about their suicidal patient tells someone about their suicidal thoughts or behaviors • No evidence at this point that medication N id t thi i t th t di ti actually increases either the incidence of suicidal thoughts or behaviors or the risk of suicidal thoughts or behaviors, or the risk of suicide
ParentsMedGuide The Use of Medication in Treating Childhood and Adolescent Depression: Th U f M di ti i T ti Childh d d Ad l t D i Information for Patients and Families Prepared by the American Psychiatric Association and American Psychiatric Association and American Academy of Child and Adolescent Psychiatry In consultation with A National Coalition of Concerned Parents, Providers, and Professional Associations As the parent or guardian of a child or teen-ager with clinical depression, or as a patient yourself, you may be aware of the recent decision by the Food and Drug Administration (FDA) to attach a cautionary label, or "black box warning," to all antidepressant medications used to treat depression and other disorders in children and adolescents. The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have prepared this Fact Sheet to help patients and families make informed decisions about obtaining the most appropriate care for a child with depression. p Depression is an illness that can affect every part of a young person’s life and that of his or her family. It can disrupt relationships among family members and friends, hurt school performance, and lead to general health problems through its effects on eating, sleeping, and exercise. If left untreated, or is not correctly treated, depression can be very dangerous because of the risk of suicide associated with the illness. Fortunately when depression is recognized and correctly diagnosed it can be treated successfully A comprehensive program Fortunately, when depression is recognized and correctly diagnosed, it can be treated successfully. A comprehensive program of care should be tailored to the needs of each child and his or her family. Treatment may include psychotherapy or a combination of psychotherapy and medication. It may also include family therapy or work with the child’s school as well as interacting with peer support and self-help groups.
In Summary In Summary • We can help most children and adolescents who suffer from psychiatric disorders, including depression –Kids need a comprehensive evaluation and an accurate diagnosis –Medication can be an important component of treatment, but medication alone is rarely the answer y –Any child on medication needs to be monitored closely –Physicians and parents need access to as much information as possible about the safety and efficacy of all treatment interventions possible about the safety and efficacy of all treatment interventions –Parents need to be advocates for their children –We need more research • Real tragedy is that so many young people still don’t receive the comprehensive and effective treatment th t th that they need and deserve d d d
Outpatient Services at UMASS Outpatient Services at UMASS • Community Healthlink, Inc. • Massachusetts Child Psychiatry • Massachusetts Child Psychiatry Access Project • Child and Adolescent Neurodevelopment Initiative Neurodevelopment Initiative • Transition Age Youth Transition Age Youth
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