Beruflich Dokumente
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Depression in adolescence
Anita Thapar, Stephan Collishaw, Daniel S Pine, Ajay K Thapar
Lancet 2012; 379: 105667 Unipolar depressive disorder in adolescence is common worldwide but often unrecognised. The incidence, notably in
Published Online girls, rises sharply after puberty and, by the end of adolescence, the 1 year prevalence rate exceeds 4%. The burden is
February 2, 2012 highest in low-income and middle-income countries. Depression is associated with substantial present and future
DOI:10.1016/S0140-
morbidity, and heightens suicide risk. The strongest risk factors for depression in adolescents are a family history of
6736(11)60871-4
depression and exposure to psychosocial stress. Inherited risks, developmental factors, sex hormones, and psychosocial
Child & Adolescent Psychiatry
Section, Department of adversity interact to increase risk through hormonal factors and associated perturbed neural pathways. Although
Psychological Medicine and many similarities between depression in adolescence and depression in adulthood exist, in adolescents the use of
Neurology (Prof A Thapar antidepressants is of concern and opinions about clinical management are divided. Eective treatments are available,
FRCPsych, S Collishaw DPhil,
but choices are dependent on depression severity and available resources. Prevention strategies targeted at high-risk
A K Thapar PhD), and MRC
Centre for Neuropsychiatric groups are promising.
Genetics and Genomics
(A Thapar, S Collishaw), School Introduction adolescents, whereby irritable rather than depressed
of Medicine, Cardi University,
Unipolar depressive disorder is a common mental health mood is allowed as a core diagnostic symptom.12 Never-
Cardi, Wales, UK; Emotion
and Development Branch, problem in adolescents worldwide,1 with an estimated theless, depression in adolescents is more often missed
NIMH-Intramural Research 1 year prevalence of 45% in mid to late adolescence.2,3 than it is in adults,13 possibly because of the prominence
Program, Bethesda, MD, USA Depression in adolescents is a major risk factor for suicide, of irritability, mood reactivity, and uctuating symptoms
(D S Pine MD); and Ta Riverside
the second-to-third leading cause of death in this age in adolescents. Depression can also be missed if the
Practice, Cardi, Wales, UK
(A K Thapar) group,4 with more than half of adolescent suicide victims primary presenting problems are unexplained physical
Correspondence to: reported to have a depressive disorder at time of death.5 symptoms, eating disorders, anxiety, refusal to attend
Prof Anita Thapar, Child & Depression also leads to serious social and educational school, decline in academic performance, substance
Adolescent Psychiatry Section, impairments,6,7 and an increased rate of smoking, sub- misuse, or behavioural problems.
Department of Psychological
stance misuse, and obesity.8,9 Thus, to recognise and treat In some respects depression in adolescents can be
Medicine and Neurology, School
of Medicine, Cardi University, this disorder is important. viewed as an early-onset subform of the equivalent adult
Heath Park, Cardi CF14 4XN, Depression is dened as a cluster of specic symptoms disorder because of its strong links with recurrence later
Wales, UK with associated impairment. The clinical and diagnostic in life.14 The illness has similar clinical features and
thapar@Cardi.ac.uk
features of the disorder are broadly similar in adolescents patterns of neural activity to that in adults, and its
and adults (panel).10,11 The two main classication systems occurrence is also associated with a family history of the
(international classication of diseases-10 [ICD-10] and disorder.11 However, important dierences exist between
the American diagnostic and statistical manual of mental the two disorders, particularly in treatment response,
disorders-IV [DSM-IV]) dene depression similarly,
although DSM-IV makes one exception for children and
Panel: Criteria for ICD-10 depressive episode
Core symptoms (at least two must be present)
Search strategy and selection criteria Depressed mood present for most of the day and almost
We searched PubMed (Medline and life science journals) for every day
articles in English using the search terms adolescent Loss of interest or pleasure in activities
depression and depression (restricted to children), combined Decreased energy or increased susceptibility to fatigue
with additional search terms, specically epidemiology, Associated symptoms
gender, puberty, diagnosis, comorbidity, aetiology, Loss of condence or self-esteem
life events, psychosocial, family, trends, genetics, Unreasonable feelings of self-reproach or excessive
gene-environment interaction, temperament, resilience, inappropriate guilt
dysthymic disorder, treatment, medication, CBT, Recurrent thoughts of death or suicide, or any suicidal
prevention, imaging, cortisol, longitudinal, and behaviour
outcomes. We also examined published reviews in the past Diminished ability to think or concentrate
decade, National Institute for Health and Clinical Excellence Change in psychomotor activity, agitation, or retardation
guidelines on adolescents with depression, American Academy Sleep disturbance
of Child and Adolescent Psychiatry practice guidelines, and Change in appetite with corresponding change in weight
Cochrane systematic reviews. We focused on papers from the
At least four of these symptoms must be present for 2 weeks to
past 5 years, but also included papers published in the past
diagnose a mild depressive episode, six to diagnose a moderate
10 years (if evidence was sparse), or published at any time (if
depressive episode, or eight for a severe depressive episode.
they were particularly important). Nearly all the published
papers were from high-income countries. ICD-10=international classication of diseases-10.
with strongly divided opinions about best treatment prac- depression is directly linked to pubertal changes in
tices.10 Depression in prepubertal children is less common hormonebrain relations.32 However, hormonal changes
than depression in adolescents or adults, and seems alone rarely produce the behavioural or neural signs of
to dier from these disorders with respect to some depression,33 and are more likely to contribute by
causative, epidemiological, and prognostic features.15,16 sensitising the brain to the harmful eects of stress.31,34,35
We focus on unipolar depression in adolescents. When Work in animals shows that oestrogen increases the
evidence is available, we focus on depressive disorder stress response in the prefrontal cortex.36 Thus, the post-
rather than its symptoms. However, in some instances, the pubertal sex dierence in depression might in part result
only available data are based on studies in which depressive from increased exposure to stressors and hormonally-
symptoms are reported. Such cases are noted, although linked heightened stress sensitivity in girls. Finally,
there are generally strong similarities in research ndings although depression is generally more common in girls,
for depressive symptoms and depressive disorder. to recognise it in boys is important. Moreover, in some
subgroups (eg, patients with neurodevelopmental and
Epidemiology medical disorders) this sex dierence might be greatly
The prevalence of depression in children is low (<1% in weakened, absent, or even reversed.37
most studies)17 with no sex dierences, and then rises
substantially throughout adolescence.18 Many factors could
Diagnostic Sample Prevalence % (SE* or 95% CI) Incidence
explain the recorded post-pubertal rise in prevalence interview size
because adolescence is a developmental period charac-
Current Lifetime
terised by pronounced biological and social changes.19,20
National comorbidity survey26
The most commonly postulated contributors are puberty
and brain and cognitive maturation. They include 1524 years (Data for 1516 shown) CIDI 1769 7 (18*) 146 (26)
Changes in taxonomy and assessment methods preclude system and brain structure and function, although no one
strong conclusions about whether or not the true prevalence pathway has been identied as causal. Prevention and
of depressive disorder in adolescents has changed over treatments have been targeted at reduction of early
time.38 Certainly, the use of depression services and and later adversities, modication of ways of thinking and
recognition of the disorder have increased, as has treatment feeling, and reduction of core depression symptoms by
in many countries.39 Youth suicide rates have uctuated alteration of biological pathways with medication.
over the same period.40 One meta-analysis found no
evidence of an increase in rates of depressive disorder in Familial and genetic risk
adolescents between 1965 and 1995.3 However, comparisons Ospring of parents who have depression face three to
of identical symptom screens across repeated epidemio- four times increased rates of depression compared with
logical cohorts have shown evidence of increasing rates of ospring of healthy parents.51 Both genes and non-
depression and anxiety symptoms in some countries.38 inherited factors contribute to this risk.51,52 Although
exposures to maternal depression in the prenatal and
Clinical outcomes of depression in adolescents postnatal periods have been regarded as especially
Longitudinal studies of community and clinic-based important,53 unlike in animals, evidence that risks to
population samples suggest that 6090% of episodes of ospring are restricted to these crucial periods is
depression in adolescents remit within a year.41,42 How- inconsistent. Longitudinal research,54,55 studies of chil-
ever, in follow-up studies 5070% of patients who dren who are genetically unrelated to their mothers,52,56
remit develop subsequent depressive episodes within and treatment trials of maternal depression57 suggest that
5 years.41,43 Clinic-referred patients generally fare less well the risk eects of early maternal depression are mediated
than those treated in the community.6 Moreover, in adults through exposure to later, continued maternal symptoms
very few individuals show complete symptomatic and or associated psychosocial adversity.58 Although the
functional recovery between depressive episodes, with importance of paternal mental health is now starting to
most reporting residual symptoms or impairment.44,45 be recognised,59 the long-term eects on depression
Finally, depression in adolescence also predicts a range during adolescence have yet to be investigated.
of mental health disorders in adult lifenotably, anxiety Inherited factors also play a part. Most twin studies
disorders, substance-related disorders, and bipolar dis- show that depression becomes increasingly heritable
order,4648 as well as suicidal behaviour, unemployment,48 from childhood (zero to low heritability) to late
and physical health problems.49 Thus, an episode of adolescence (modest heritability, around 3050%).60 The
depression during adolescence often heralds a chronic or heritability rates during late adolescence are similar to
relapsing disorder, and forecasts a broad range of those seen in adult life.60,61 Inherited liability for
psychosocial diculties and ill health. depression manifests in dierent ways and at dierent
times. Family and twin studies60 suggest that anxiety and
Cause and pathogenenesis depression share inherited liability, but anxiety in
Because of the clinically heterogeneous and diverse causes childhood tends to precede later depression during
of the illness, to understand the pathogenesis of depression adolescence. Some genetic risks are shared with
in adolescents is challenging. Like many other common disruptive behaviour problems.62,63 Several workers have
health disorders, several risk factors interact to increase suggested that adolescent-onset depression, like other
the risk of depression in a probabilistic way. To assess the early-onset forms of illness, such as breast cancer,
contribution of any single risk factor in isolation and to represents a more strongly genetic subform of depres-
identify crucial developmental periods when exposure is sion,64 but consistent evidence is scarce.65
especially risky is dicult because many individual, Some studies have focused on identifying specic genes
family, and social risks are strongly correlated and relate to that increase susceptibility for unipolar depression. So
continuing and later adversities. far, no replicated, signicant ndings have emerged.66,67
Distal risks such as inherited factors and adversity in These negative ndings for unipolar depression contrast
early life might directly and indirectly predispose to with those for other psychiatric disorders such as
depression. Such risks could mediate their eects schizophrenia and bipolar disorder, perhaps because
through temperament and personality attributes (nega- genes operate in more complex ways for depressive
tive emotionality, decreased positive emotionality and disorder than we currently understand, or because opti-
attentional control, behavioural inhibition, and neur- mum genetic research strategies have not been used.
oticism) and cognition.50 However, consistent evidence is
sparse as to whether such characteristics are risk factors, Psychosocial risk factors
mediators, or consequences of depression. Much research has been done into the association
Distal factors, together with hormonal and maturational between depression and environmental factors such as
changes can also alter individual sensitivity to stressors. exposures to acute stressful events (eg, personal injury,
These risk factors in turn aect proximal biological risk bereavement)68,69 and chronic adversity (eg, maltreatment,
mechanisms such as changes to the neuroendocrine family discord, bullying by peers, poverty, physical
illness). Nevertheless, such exposures do not always lead in the context of maltreatment or a medical illness.87
to the development of depression in adolescents, although Thus, although thought to be controversial by some
those at high genetic risk seem to be especially susceptible researchers,85 these ndings are promising.
to the eects of such stressors.70 Stressful life events
seem more strongly associated with rst onset rather Brain and neuroendocrine mechanisms
than recurrence of depression,71 and risk is considerably Both inherited factors and psychosocial stressors can be
greater in girls,29,72 and in adolescents who have multiple thought of as distal risk factors, which determine the risk
negative life events than those exposed to one event.71 for depression by shaping more proximal biological
Chronic, severe stressors that aect relationships seem mechanisms such as activity in underlying neural circuits
most important. Negative family relationships,73,74 peer and endocrine systems.88 The similarity of ndings in
victimisation through bullying,75 and maltreatment are adolescents and adults suggests that core biological
common risks for depression. features are shared.
Some children exposed to the traumatic events of war, Work in animals not only has shown that the immature,
torture, displacement, orphanhood, or HIV infection76,77 adolescent brain is more susceptible than the adult brain
might develop long-term psychiatric disorders, especially to the eects of these genetic and environmental
if there is a family history of such disorders, or they are inuences,89,90 but has also identied specic brain
exposed to multiple traumas.78 Although recorded associ- regions where changes in circuitry occur.90 Moreover,
ations between psychosocial stressors and depression these regions seem to be the same ones implicated in
could show the eects of unmeasured confounders and human brain imaging studies. Two interrelated neural
reverse causation, ndings with dierent research circuits and associated modulatory systems have been
designs consistently show genuine causal risk eects. closely linked to risk for depression, both in adults and in
adolescents. These circuits are active in the response to
Geneenvironment interplay danger and learning about rewards.91,92
Inherited factors seem to contribute to depression in One circuit connects the amygdala to the hippocampus
adolescents in two waysnot only by directly increasing and ventral expanses of the prefrontal cortex (PFC) and is
risk, but also indirectly through geneenvironment linked to hypothalamic-pituitary-adrenal (HPA) axis activ-
interplay, specically by increasing sensitivity to adversity ity. Activity in this circuit consistently seems raised in
(geneenvironment interaction) and by increasing the patients with major depression, and both established and
probability of exposure to risky environments (gene novel treatments for depression could work through
environment correlation).60,79,80 Several twin and family reduction of its activity.93 Some of these neural changes are
studies suggest that adolescents (especially girls) at high also seen in healthy, at-risk individuals, such as in
inherited and familial risk of depression show increased those with particular temperament types (behaviourally
sensitivity to psychosocial risk factors (geneenvironment inhibited)94,95 and those at high familial and genetic risk for
interaction), such as stressful life events81 and family depression.94 Perturbations in this circuit link depression
adversity,60,80 and are the ones most likely to be exposed to to stress-related enhancements in HPA-stress systems,
such risks.80 such as higher than expected cortisol concentrations,96,97
Do specic gene variants moderate the eects of and activity in the serotonergic system.
adversity on brain function and clinical outcome? Many Genetic factors, psychosocial stress, sex hormones, and
reports suggest that a variant (5-HTTLPR) in the sero- development have also been linked to changing activity
tonin transporter gene might increase risk of depression, in this circuit,84,94 with evidence that this circuit matures
but only in the presence of adverse life stressors or early after adolescence. High concentrations of sex steroid
maltreatment.82,83 The ndings are less robust in adoles- receptors have been identied within this circuit,23 and
cent boys than in girls.83 Importantly, this same gene might provide a biological mechanism for why girls have
variant has also been reported to aect fear-related higher risk of depression than boys.
and danger-related brain circuitry that is altered in The other key circuit implicated in depression
depression; specically it is associated with increased encompasses the striatum and its connection to both
amygdala activation in healthy individuals in response the PFC and ventral dopamine-based systems. Like the
to viewing fearful faces.84 However, such ndings in rst circuit, this one also continues to mature through
relation to depression and depression-related brain adolescence. Sex dierences emerge in both circuits.98
mechanisms seem to vary not only by genotype, but also Research into this reward circuit implies that reduced
by age, sex, and severity of symptoms, and are also activity is linked with expression of and risk for
reliant on good quality measures of adversity and depression. Reduced striatal and PFC activity during
depression. Although one meta-analysis failed to tasks involving rewards has been recorded both in
support the 5-HTTLPR gene-environment interaction individuals with major depression and in those
nding,85 it was criticised on many grounds,83,86 and a re- with depressed parents.99 Both inherited factors and
analysis of data showed signicant evidence of the stress-related perturbations seem to contribute to
importance of gene-environment interactions, especially these changes.100
studies have shown it also works well for adolescents.112,113 in major depression. Treatment is very dierent for the
The full 25-item strength and diculties questionnaire three conditions. Patients with bipolar disorder can also
(SDQ) provides additional screens for attention decit present, like patients with depression, with agitation and
hyperactivity disorder (ADHD) and disruptive behaviour irritability. Chronic non-episodic irritability which is a
symptoms.114 Other measures focus on depression alone core feature of a recently dened syndrome of severe
and include the short mood and feelings questionnaire,115 mood dysregulation is not the same as bipolar disorder,
and the childrens depression inventory.116 These ques- but seems to be a strong predictor of future depression.122
tionnaires can be used as an additional screen in Two-thirds of adolescents with depression have at least
adolescents if there is some uncertainty about the one comorbid psychiatric disorder and 1015% have two
reliability of the responses to the PHQ-2 or SDQ items, or more comorbidities.28 Adolescents with depression are
and as an adjunct to monitor change (gure 1). six to 12 times more likely to have anxiety, four to 11 times
For individuals who score above the cuto scores a full more likely to have a disruptive behaviour disorder, and
clinical assessment should be undertaken to reliably three to six times more likely to have a substance misuse
diagnose depression. This assessment consists of sensitive, problem than are adolescents who are not depressed,
empathic questioning about symptoms of depression with adjustment for multiple comorbidities.123 For
(panel), their duration, severity, and any associated example, almost 20% of adolescents with depression also
impairment through a direct interview with the adolescent. meet diagnostic criteria for generalised anxiety disorder,124
It might be necessary to interview them separately from with reported lifetime rates of 5070%.125 Depression can
accompanying adults for part of the consultation. also complicate eating disorders, autistic spectrum
Information provided by a parent or guardian is important disorders, and ADHD.
because diagnoses based on the accounts of several Comorbidity is especially increased in adolescents with
informants show greater reliability and validity.117 The risk severe depression,126 and predicts severe impairment,
of suicide and how the adolescent functions at home and poor long-term outcome,126 and complicates treatment.127
school should be assessed. Possible warning signs include The high level of comorbidity can be explained in part by
a decline in academic achievement or engagement in shared risk factors for multiple disorders, but could also
leisure activities, changes in peer and family relationships, arise if comorbid disorders are risks or consequences of
and social withdrawal. The best strategy for clinical depressive disorder. When a patient with a depressive
assessment by non-specialists has yet to be determined. disorder also has another psychiatric disorder, the
Training programmes to improve detection and diagnosis depression should be treated in its own right, with the
of depression have not proved consistently successful. An understanding that additional interventions will be
alternative strategy would be to assess the use of needed to address the specic comorbidity. Patients with
standardised structured diagnostic interviews such as the medical illnesses such as diabetes or HIV/AIDS can have
freely available development and well being assessment.118 comorbid depression. The value of distinguishing
between primary and secondary depression in the context
Dierential diagnoses and comorbidities of another disorder is not clear because there is growing
Two diagnoses in classication systems that are evidence that the relation between medical illness and
characterised by prominent depressive symptoms and depression is often bi-directional,128 and treatment of
associated impairment but that do not meet the criteria to depression is still needed. The extent to which dierent
diagnose major depression are adjustment disorder and comorbidities might be associated with heterogeneity in
dysthymic disorder. Research into the validity and cause, prognosis, and treatment remains unclear.
treatment of these disorders is sparse. Adjustment disorder
is short-lived, arises within 3 months of the onset of a Treatment
stressor and does not persist longer than 6 months after Treatment data in adolescents have been reviewed
the desistance of the stressor. Dysthymic disorder describes (gure 2).10,129 Three important issues are highlighted.
a pattern of chronic symptoms of depression that are First, treatment choices are not the same in adolescents
present for most of the time on most days with a minimum as in adults. Second, best treatment practice is contro-
duration of 1 year for children and adolescents. Sometimes versial because accepted practice and clinical guidelines
individuals with dysthymic disorder have superimposed vary in dierent countries, and because of concerns
episodes of major depression onto their usual symptoms. about the use of antidepressant drugs in patients younger
Although bipolar disorder and schizophrenia are much than 18 years, with some recommendations based on
less common in adolescents than is unipolar depression consensus rather than on evidence. Third, the evidence
(prevalence is <011% for both),119121 they are important relates to the short-term eectiveness of psychological
dierential diagnoses to be remembered. Both disorders treatments and medication. Evidence for the long-term
can be preceded or accompanied by depression or benets of treatment to rates of recurrence and for the
symptoms of depression, but they have other key eectiveness of non-specialist interventions is scarce.
featuressuch as episodic elated or irritable mood or The two best studied psychological treatments are
enhanced energy in bipolar disorderthat do not occur cognitive behavioural therapy (CBT) and interpersonal
symptoms of depression in adolescents.142 Counselling compared with an untreated group (214% vs 327%).148
programmes in schools and primary care are being However, the prevention was less eective in those who
introduced in some countries that could oer a more had a parent with current depression. This result, coupled
pragmatic way of initially dealing with mild or sub- with that of a treatment study of adult depression showing
threshold depression in adolescents and improve access that remission of maternal depression was associated with
to treatment for this group.143 Other less expensive benets to their osprings mental health,57 suggests that
approaches that could also be used in primary care, eective treatment of parental depression is important for
delivered through the internet or by non-specialists are the adolescent with depression. Preliminary evidence
now being investigated for use in adults with depression, from a systematic review suggests that school-based CBT-
but have not yet been widely assessed for adolescents. oriented prevention is a promising approach (reported
A report by a special WHO panel has drawn attention eect sizes of 021140) when targeted at adolescents
to the importance of treatment of mental health disorders who report high rates of depression symptoms.149
in low-income and middle-income countries where Although there is less research on depression to inform
resources are scarce, with depression in adolescents practice in low-income and middle-income countries
identied as a key priority area.144,145 One promising than in more developed countries,150 interventions such
approach is the treatment of mental health problems in as training in positive thinking and conict resolution
children exposed to traumatic events with IPT delivered have been noted to reduce the rate of depressive
by trained local community workers. A well designed, symptoms.151 Other strategies such as parenting pro-
RCT examined the ecacy of IPT in adolescent survivors grammes have also been developed, which might be of
of war and displacement in northern Uganda. The study particular importance in view of the high rates of
recorded that IPT delivered by local community workers maternal depression worldwide and parenting problems
signicantly improved symptoms of depression in in these circumstances, although consistent evidence for
adolescent girls.146 reduced rates of adolescent depression outcomes is
scarce.152 These approaches and psychological therapies
Prevention such as IPT could be especially helpful for those children
In view of the disability associated with depression in exposed to trauma and identied as belonging to a high
adolescents, prevention or at least delay of onset of the risk group,78 but have not been widely studied in a
disorder is important.101,129 Prevention strategies could be preventive context. Quality of relationships seems key to
aimed at reduction of modiable risks and promotion of enhance resilience in high-risk children. Thus far not all
factors to protect high-risk children from the eects of prevention programmes have targeted this issue.
adversity and interrupting risk pathways. Prevention
methods have been much discussed in an Institute of Conclusion
Medicine report and a meta-analysis.101,147 Both concluded Despite the global importance of depression in adoles-
that a targeted and indicated prevention strategy is eective cence, many knowledge gaps exist. Further development
in preventing the development of depression in adolescents of pragmatic, cost-eective methods of detecting, assess-
whereas universal prevention is not. ing, and treating adolescent depression in non-specialist
Government policies that address social inequalities are contexts and low-income and middle-income countries
potentially important but consistent evidence of reduced is an important priority in view of the scarcity of
rates of depression in adolescents in countries with few resources. The knowledge gap with regard to relapse
inequalities is scarce. Some countries have introduced prevention is also noticeable. Finally, prevention strat-
prenatal and preschool (age 05 years) child development egies seem important because of the complexities and
programmes that aim to provide support, reduce early costs associated with treatment of depression in
adversities, enhance early stimulation at home, and adolescents. However, what the key components of
improve parenting in high-risk families.101 Such preven- these programmes and policies ought to be is not yet
tion strategies seem to have some immediate and con- clear. Cost eectiveness must also be determined. Such
tinued positive eects on cognitive ability and antisocial strategies need to be a priority for future research.
behaviour, but consistent evidence with regard to preven- Contributors
tion of depressive disorder in adolescents is scarce. All authors contributed to the research, interpretation of research,
Depression-specic prevention strategies consist of a writing, and editing of the manuscript.
combination of education about depression and CBT Conicts of interest
strategies applied to children and parents. These strategies We declare that we have no conicts of interest.
have been targeted at three risk groupsthe ospring of Acknowledgments
parents who have had depression, adolescents with The authors research on depression is funded by the Sir Jules Thorn
Charitable Trust. SC is supported by the Waterloo Foundation. We thank
subthreshold symptoms of depression, and adolescents Sir Michael Rutter, Antonio Munoz, Robert Potter, Gemma Lewis, and
who have had a previous depressive episode. A large RCT Miriam Cooper for comments on an earlier draft, Robert Goodman for
showed that a group CBT programme reduced the advice, and Peter MacSorley (medical student) for assistance with the
incidence of depression in treated adolescents after 1 year literature search.
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