Depressive Disorders in Children and Adolescents: Identification and Treatment

Elizabeth McCauley, PHD, ABPP Professor

University of Washington/Seattle Childrens 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 symptoms79% 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 Model Diathesisvulnerability Biologicalgenetic, temperament STRESS GENE ?? Environmentloss, abuse, neglect, demoralization Cognitive Stylenegative cognitive style, see cup 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 Adolescence Puberty stimulates changes in brain systems regulating arousal and appetite that influence intensity of emotion and motivation 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

Late Adolescence With age and experience comes maturation of frontal lobes which facilitates regulatory competence

Case Presentations
14 year old male, first semester of high school, bout of the flunever 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/youths persepctive

Assessment Tools
Why Use: Raise adolescents 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).

Childrens 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 format13; 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/youths sense of what treatment will be useful Differential trajectorieshopelessness 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, breakups, 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

Depression

Kendalls Coping Cat; Marchs OCD Tx Social Effective TxBeidel Exposure/Transfer of Control-Silverman CBTClarke, Lewinsohn Interpersonal

ADHD

ODD/CD

Family, social skills, attentional skills training Parent-child Interaction TherapyChamberlain The Incredible Years Webster Stratton Parent/Child Treatment for AggressionBarkley, Kazdin

Psychotherapy--Mufson Behavioral Activation

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 mightchange 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 mightchange 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

100% SSI Tricyclic 80% Other

60%

40%

20%

0% Start 1 2 3 4 5 6

Months after initial prescription fill

Richardson, DiGiuseppe, Christakis, McCauley, Katon, 2004.

Psychotherapy for Depression: Evidence of Treatment Effects

Weisz, McCarty & Valeri

Reinecke, Ryan & DuBois 6 CBT Trials Lewinsohn & Clarke 12 Trials Michael & Crowley 14 Trials 35 Trials Inc. TADS N=439 IPT- 2 trials

ES = 1.02 (0.97) 1998

ES = 1.27

ES = .72

ES = .34 (0.40 ULS)*

1999

2002

2006

Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149

* Unweighted least squares

2007
Adjusted mean Children's Depression Rating Scale-Revised (CDRS-R) total scores

The TADS Team, Arch Gen Psychiatry 2007;64:1132-1143.

Moving on with Treatment

CBT-the most widely investigated psychotherapy for depression 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

Aaron T. Beck

Require ability to reflect on, monitor, and evaluate own thinking process in midst of heightened emotional arousalmay not have skills on board

Moving on to TreatmentWhat Works Best?

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

Principles of CBT: Technology

Agenda Setting Mood Monitoring Behavioral Activation; Structuring Activities The ABCs 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 ABCs of CBT: Linking Affect, Behavior, & Cognition - What was the situation? - What were you thinking? - How were you feeling? - What did you do? Thought Records

Supplementary Materials
Thought Record
What happened? How did you feel? 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 time. Did you feel some more than others?

What does it mean to you that.? So what? What if?

Did you want to do something you didnt do? Do something you wish you hadnt?

Do you feel differently if you think about it this way? Would you do anything differently now?

Middle Sessions:
The ABCs 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 patients treatment focus Provide patient with an interpersonal case formulation

Interpersonal Inventory
Ask about significant people in the adolescents 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 didnt 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 adolescents 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 persons perspective -putting yourself in other persons 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 teens 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

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
Peter Lewinsohn

Focuses 3 core strategies: Allows adolescent to practice with coach planning, Facilitative monitoring and evaluation Activation skills needed to coordinate Processes that inhibit activation: affect arousal and cognitive Withdrawal skills w/o direct challenge to Avoidance beliefs Ruminative thinking

Thanks!