Depression in the Young: A CME Talk For Doctors
*Kevin: nice "C" student, quiet who thinks of putting a wire in the electrical socket. Depression.
*Tom: aggressive oppositional annoying child. Irritable youth are at times irritable from Depression.
Major Depression is the leading cause of disease burden: in women 1/5 and 1/10 in men in lifetime. It often begins in youth with very serious consequences.
Significant Major Depression Consequences for Youth
Suicide: University of Louisville School of Medicine--of 341 youth referred for suicidal behavior 43% were under 13.
Adolescent suicide has increased 4x since 1950 and represents 12% of adolescent death.
Suicide is third leading cause of death in adolescents (After accidents and cancer).
30% of high school students have had serious suicidal thoughts
19% have thought of a specific suicide plan
11% have tried to kill themselves (Often do not report it, do it when upset and impulsive and are ignorant of lethal means--"took 6 Tylenol.")
School work can go from good grades to fair/poor--depression decreases concentration. School trouble can orient someone toward peer groups that are not pro-education.
Socialization can be severely impaired and not quickly recovered--negotiating peer/opposite sex/parent/teacher rules of engagement are very hard for the depressed youth. They are often irritable, withdrawn, and do not enjoy relating.
Dangerous acts can increase with Major Depression and Bipolar Depression--impulsive driving, fighting, reckless sex, and increased drug use are all increased.
Core Beliefs about intimacy, attachment, hope, the world, and people can be formed with black depressive glasses and set paradigms for life.
Frequency of Major Depression (MD)
2% of children, 5% of adolescents
Becoming more common in children probably because of environment, diet, toxins, family trouble, stresses and better diagnosis.
The more relatives with depression, anxiety, bipolar disorder, ADHD, or substance abuse- the more depression
If the parents are depressed, the children are 3X more at risk
If one parent has had MD, their child has a 25% lifetime MD chance
If two parents have had MD, their child has a 50--75% lifetime MD chance
76% concordance rate for monozygotic twins reared together. (These twins are from the same egg).
67% concordance rate for monozygotic twins reared apart
19% concordance for dizygotic twins
A child with a bipolar first degree relative has a 25x higher risk vs. a control
General Criteria of (Unipolar) Major Depression
APPROXIMATELY FIVE OF THESE NEED TO BE PRESENT FOR TWO WEEKS
*irritable or sad mood most days (In child mania there can also be profound irritability)
*excessive boredom and loss of interest in most pleasures (does not have to be 100%)
*weight loss, failure to gain developmental weight, or excess gains
*major sleep increases or decreases on most days
*slowed motor movements or agitation (In mania body restlessness is marked.)
*fatigue most days (possibly the most common symptom of depression)
*excess guilt, feeling worthless
*labored or slowed concentration (in the elderly depression can look like dementia)
*thoughts of death, suicide and hopelessness
Depression in Infants (Briefly)
We unfortunately have extensive accounts of children raises in orphanages, hospitals, along with controlled primate experiments that show severe depression can occur in infants. Its continued manifestation can lead to severe and permanent brain damage.
Infant depression is intensely associated with caretaker availability and attachment potential. Infants, like all children are intensely sensitive to their emotional environment.
An infant having merely their bodily needs met (clothing, food, hygiene) can still develop elements of major depression, significant developmental delays, and diverse neurological damage.
*A mother who can force herself to look expressionless and emotionless at her child for a full three minutes--as the child seeks to engage her--can induce withdrawal, gaze avoidance, a hopeless affect, and passivity in her child.
*EEG studies of depressed mothers show that an infant's EEG can take on characteristics of the mother's depressed brain.
Depression in Children 1-3 years old (Very Briefly)
*Developemental delays and regressions of past abilities
*Poor curiosity (in otherwise healthy infant)
*Distrust or indifference to people/ indifference to play
Depression in 3-5 year old children
*30% of 3 year olds are "hyper" and Amon reports this drops off significantly, i.e., to 5% in four year olds. Agitation is a symptom of depression. (Severe agitation can also be a symptom of mania or bipolar disorder.
*regularly angry, labile mood and oppositional
*somber and sulky affect
*many bodily complaints
*play themes of failure, being punished, getting hurt, and death
*an increase in great magical fantasies, then a decrease if child gets very hopeless
*a decrease in group play
*lost abilities, e.g., unable to button shirt (harder to concentrate)
*separation from primary caregiver is harder, increase in clutchiness
*head banging, self-scratching, swallowing non-food items
Depression in Children 6-12 years old
*Concrete teacher observations are helpful, since they have many other children as "controls."
*Crucial to get both child and adult input (As a trend children will talk of feelings if you probe and adults are helpful with the concrete behavior, e.g., sleep and aggressive behavior).
*Children will sometimes look at pictures without clear themes and make up stories--depressing and hopeless stories may show depression.
*Are not all kids moody? Key is duration and is it present in most environments. Also keep in mind other depression criteria, e.g., no pleasure and sleep abnormalities. If a child has a strong family history of depression, then you also must watch for depression more closely.
*Depression in this age does not mean complete absence of all pleasure. Many depressed children still like Nintendo, TV, and perhaps one other thing. However, generally they show a decrease in interests, e.g. from 6 to 3 things, and less passion about the things they like. 50-90% 0f depressed children are constantly and quickly "bored." A parent can feel that it is impossible to make them happy.
*They can feel "stupid." Depression makes it harder to think
*Worries can increase because anxiety is a symptom of depression, depression makes you more narcissistic, and you have less hope. (SSRI medications like Zoloft and Prozac help child anxiety probably even more than adult anxiety.)
*Somatization increases--headaches, stomach pain. The older depression scales had large numbers of bodily sensation questions. It is very likely depression increases the pain experience.
*School skills and social functioning fall off--both are challenging to a small child and show impairment since the child is not at his/her peak.
*Fantasy/Make up stories--filled with loss, rejection, injury and similar topics.
Child Depression Scales--there are a number available. Kovacs has a useful one, the Children's Depression Inventory with a parent version also--
*this children's scale is probably at a first or second grade reading level
*it asks a child to choose between three choices--it may tax their abilities since there are three choices and 27 questions. It is often helpful for parents to read the test to the child with a few breaks, but even then some children are not cognitively mature enough or alert enough to do it.
*the scale is scored 0,1,2 with the most depressed answer giving a 2. The maximum score is 54. A 19 or above should raise clinical suspicion, though no scale, even structured ones can catch every child.
Depression in Adolescence
Because we expect turmoil in this age group from stress, sexual hormones, and poor skills at coping with increased feelings and aggression, we can overlook it
Scales--a number of diagnostic scales are available to help. We will only discuss a few simple ones.
Paul Ambrosini has shown the Beck Depression Inventory can sift moodiness from Major Depression in adolescents.
Inventory to Diagnose Depression--from Mark Zimmerman of Brown University. Many older adolescents are capable of using and filling out. If a child has great variability in mood, I have them complete it every week to see the trend. Variation on the score could be stress variation, personality style, or bipolar cycling.
Basic definition: depression and mania which can occur at different times or at the same time.
*Sample mania symptoms (grandiosity, pressured speech, racing thoughts, severe agitation, and major impulsivity).
*Major shift in expectations of presentation since 6/95
The view that bipolar patients have simple neat cycles of sadness followed by eccentric euphoria is gone. Some of the changes:
Seasonal Affective Disorder
*it exists in children, and some adults recall it started when they were children
*fatigue, decreased school function, irritability
*standard treatment is a 10,000 lux sun machine
*see sample abstract on its use. Standard practice since 1988 and written about since Aristotle.
*morning use is better than afternoon
Major Depression Usually Comes With Other Emotional Problems
Along with major depression, youth often have ADHD, separation anxiety, phobias and fears, somatic bodily complaints, substance abuse, trouble with school and behavior problems.
Adult study by Zimmerman shows that the practitioner who only sees major depression is usually missing other things.
ADHD--children with this often have depressive disorders. A common clinical error clinically is that a comorbid depression is missed and stimulants are used. They work initially and then slowly lose their effect--so they are increased, and finally the child becomes very depressed and has burned out stimulants. Repairing the pharmacology on these cases takes some time. Antidepressants must be used before stimulants, when both depression and ADHD are present.
Personality Disorders--Depression can cause a child to be more narcissistic, naively idealistic, very clutchy, nasty, avoidant and creates personality disorders which leave when the depression leaves.
Increased Psychotic Risk--Early depression means increased risk of psychotic depression (esp. with auditory hallucinations).
Learning Disorders or Trouble--Various learning deficits can co-exist with depression, but depression alone causes school to be harder because thinking is slowed (Common for an "A" student to drop to a "C" or even an "F").
Social Deficits and Impairment--time spent picking up relational skills is lost or at least reduced because of greater narcissistic injury (thin skin), the energy to relate is too taxing, people feel easily annoyed, or because you just prefer to be alone.
Eating disorders--often have comorbid depression. Medications help but only modestly.
Cigarette Smoking--an antidepressant stimulant. After depression is treated and independence issues with parents are settled down, some teens find it easier to quit.
Marijuana Use--rare acute use versus chronic use
>Drug Abuse/Alcoholism--at times desperate attempts to ward off depression.
For all children over fourteen with new onset mood disorders I get a comprehensive toxicology screen including inhalants, hallucinogens, and a quantitative marijuana level--THC and key metabolites, e.g., delta-9-THC-9-carboxylase level--helps contrast rare from serious use.
A comorbid substance problem must always be addressed in an integrated way with psychiatric medications. Most antidepressants work poorly in the presence of regularly used illegal drugs and regular alcohol. Alcohol abuse is hard to detect in youth by any sophisticated blood test.
Rule out Medical Illnesses and Eliminate Depressing Medications
Parent Input and Treatment
We always need the parent. They must be part of the initial evaluation.
Pennsylvania Law saws a child 14 and older can have confidential psychiatric care.
I prefer a brief note from a parent on any new misadventures from the week (which the child sees), and allows critical parent input.
In child psychiatry you always need to empower and assist the parent.
Parenting is truly the impossible profession -- "good enough" is commendable.
Treat parents if they are overwhelmed with child care, past abuse, or have depression themselves. Depression will make most parents decrease their empathic capacities--thus pulling the rug out from the child--especially a single parent with a chronic long-lasting depression.
Child Depression Treatment
Consider and evaluate all the factors contributing to the child's mood.
A mild depression often precedes serious Major Depression by 4-5 years. We have a precious small window of opportunity to prevent self medication by drugs/alcohol, serious school failure, impulsive risk behaviors, and suicide.
Medications for Depression
We have used anti-depressants for children for decades. The research, however, is only fair for many reasons. For example, there has always been a shortage of child psychiatrists, and a shortage of money to fund studies. Even though we have been using medication in child psychiatry since the 1930's, we have not always been clear on the way depression presents in children, and especially the way to test a pure group of children with only "major depression."
Tricyclic Antidepressants (TCA's)--
--these represent a good example of the greatest struggles in child medication treatment.
*children are very sensitive to a whole host of factors and therefore their placebo rate is roughly 2X that of adults.
*studies often did not have enough children to show a statistical difference.
*since we now know that child depression puts one at greater risk of bipolar disorder, some of these children in the studies may have been made worse because of the antidepressant stimulating an irritable mania.
*some had only mild to moderate depression (if you give them attention, they fall in love, or their situation improves, they snap out of it easy).
*medication trials were only 4-8 weeks and of an insufficient dose. Children with severe depression often have a greater genetic depression history and therefore may need higher doses and longer durations.
*TCA's work on the noradrenergic system and it is not fully developed till early adulthood.
*children's livers can rapidly deaminate the TCA and make it less potent.
The Usage of TCA's Today
No longer first line because they require blood levels, careful cardiac monitoring (serial EKG's), cause weight gain and might cause very rare cases of arrhythmia.
Treatment with SSRI's
Good study showing benefit--Emslie studied 96 unipolar depressed children and adolescents after a one- week placebo wash out. Drug patients received a maximum dose of 20 mgs. of Prozac for 8 weeks and medication beat placebo 56% to 33%. (Archives of General Psychiatry 54:11:1031-1037,1997).
SSRI's Treatment Strategies
*never start with the PDR recommendations. Start very low with, e.g., 5 mg. of liquid Prozac, 12.5 mg. of Zoloft or 5 of Celexa.
*An anxious child, a child with a strong family history of bipolar disorder, or a child afraid or ambivalent about medication, perhaps should be started lower. Anxious children are very sensitive to the serotonin stimulating effects of SSRI's when they are first started. (Handout # 34 for SSRI side effects--generally only reversible anorgasmia is found at steady state).
*Before you declare a medication a failure give it a full trial, e.g., Prozac 120 mg. for ten weeks or Zoloft 300 mg. for ten weeks.
*Try two SSRI's before moving to another class because sometimes one works when another does not.
*Never suddenly stop an SSRI unless it was just started (handout # 35,36).
*Little data but being used increasingly. Low interactions if you combine it with other antidepressants.
*Effects both the noradrenergic and serotinergic systems and therefore may work faster.
*No need for mandatory blood levels or EKGs (Peak blood levels can be useful).
*In youth watch for blood pressure elevations and sedation--they are somewhat more sensitive to these side effects.
*Like many medications dose increases may be necessary to maintain gains--research blood levels show drops in blood level over long periods--unpublished data.
*little child research has been done. Great for skinny kids taking stimulants with poor appetite.
*weight gain may turn off some weight conscious adolescents
*effects both the noradrenergic and serotinergic systems
*only a small amount of research in youth
*Now available in slow release, which if not crushed, gives less peaks, i.e., less seizure risk. Wellbutrin should not be used in epileptics, individuals with severe head injuries, alcohol abusing youth, or youth who binge and purge.
*Used by some to treat both ADHD and Depression. It probably helps roughly 30% of those with ADHD symptoms.
*Low child research, but being used.
*low side effects and may particularly help anxiety.
*derived from trazodone which has a migraine producing metabolite. Serzone has a low level of this metabolite, and so it probably is not a problem for children with comorbid migraines.
*1/300,000 patient years one finds a likely liver fatality. If on the medication take a liver protecting nutrient--about 7 I know.
*It is a far cry from One Flew Over The Cuckoo's Nest.
*It is now commonly an outpatient procedure, with very low current placed on the non-dominant hemisphere.
*there is extensive evidence that current ECT techniques are not associated with long term memory impairment. If someone does not respond their memory may not be the best due to the memory problems of depression.
*ECT is used worldwide, occasionally, in adolescents and even children with a good rate of response.
*A last option which is rarely used in kids these days. If a choice between death by suicide and ECT an easy choice?
Trans-cranial magnetic stimulation
*Multiple centers in the United States
*minimal side effects, more selective to the area of brain stimulated than ECT. Research shows some promise.
Monoamine Oxidase Inhibitors
*Strong antidepressants that are never first line medications. They require diet and medication restrictions, e.g., no soy sauce or pseudoephedrine.
*Manerix is the best one to use because it has no serious diet restrictions, is in over 50 countries and has been in regular use since 1988. It does not have FDA approval. It still cannot be mixed with many other drugs, but at least people can eat regularly and it has few long term weight or sleep problems. It must be imported.
Selegiline is now in a patch. Metabolites are stimulants as we have published previously, so not going to be great for anxiety. You can eat a regular diet. Other MAOI's in America require some diet limitations.
St. Johns Wort
*Commission E German research is the OK data.
*roughly 40 world studies which generally show some use for mild-moderate depression.
*the herb has many psychoactive antidepressants.
*some individuals might be more sensitive to sunlight, esp. at doses over 900 mg.
*Taken by some rare youth but research is early yet.
Augmentation of Antidepressants
*Lithium, short term T3 (not Syntroid) thyroid hormone, SAMe, L-5-HTP and other antidepressants are options. There are dozens of less researched strategies.
Depression Treated with Psychotherapy
Ask a child to tell 20 make up stories and you start to hear core beliefs about people, loved ones, and the world. The stories start to sound like repetitions--sometimes of one story.
If a child believes any of the following, they may be 60 years old and still trying to fix these core beliefs:
"No one loves me but me"
"I exist to care for others not for myself"
"No one can protect me"
"I am alone"
"I am ugly"
"I am stupid"
"Nothing can change--I am trapped"
"My gender is second class"
*These are all example of beliefs that promote depression. They are not easily helped by a few quickie therapy sessions.
*Generally, in therapy you get what you put into it. Two sessions/week is four times as helpful as once/week.
*Severely depressed children need supportive therapy--nothing that breaks down defenses--depression itself breaks down defenses.
*Therapy and medication are a strong combination to prevent relapse.
*If children express anger they are less likely to kill themselves. Teach that there are assertion options besides depressive withdrawal and angry outbursts.
*Therapy is work not magic. Sometimes children are worse at first because of the emergence of strong feelings. But it can create mastery of terrible losses and healing.
*If children talk out feelings, they are less likely act them out. Specifically,. they are less likely to run away, fight, hurt themselves, take the car, or have impulsive sex.
*Emotional literacy is a powerful antidepressant, yet takes time because knowing why you yelled at your mother or father is not always clear.
Family Therapy and Depression in Youth
Youth can act indifferent, but they are often the rubber link in the metal chain.
Children and adolescents are very sensitive to changes in their parent's marriage, sibling problems, moves, losses, peer rejections and new schools.
Divorce--co-parent with civility.
--if the child looks like your X-spouse it is easy to disconnect from them, and this abandonment can make the child depressed.
Blended Families--the child's family are the original parents. Some children become very depressed and resistant to new love interests--keep the pace of any new parental romance slow. Do not expect "Mary" to adopt anyone as a "new father."
160,000 children miss school daily because of fear of intimidation from other students.
About 76% students say they have been bullied and about 15% report "severe reactions" to the abuse
Role play, teasing extinction techniques, self-defense training, parent or legal intervention
Anger management skills, assertion options and learning less cognitively
Cognitive Distortions Therapy
I have samples showing ways of thinking which can promote depression in youth. Studies show it is quite helpful with youth because they often think and feel in extreme.
Sometimes in poorly verbal children you can use types of play to re-enact a depressing trauma and play out a new ending. A metaphor for this technique is nightmare treatment: the person imagines a new ending to the nightmare and it slowly becomes incorporated into the dream as the ending.