Transcript Epidemiology in Child and Adolescent Psychiatry

Dr Jonathan Lyons
ST5 in CAMHS
Ivry House, Ipswich
CAMHS gender ratios
Options:
 1:10
 1:6
 1:4
 1:2
 1:1
 2:1
 4:1
 6:1
 10:1
 Select the female to male ratios for the following conditions
A.
B.
C.
D.
E.
F.
G.
Autism
Asperger’s
Adolescent depression
Tourette’s syndrome
Child ADHD
Bulimia nervosa
Childhood (pre-13) depression
Co-morbidity in adolescent depression
Co-morbidity among moderate to severely
depressed adolescents attending routine NHS
services reaches which of the following:
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%

Treatment in adolescent depression
Treatment of adolescent depression brings
forward onset of recovery when compared to
naturalistic outcomes by which of the
following:
A: 1 to 2 weeks
B: 2 to 6 weeks
C: 4 to 12 weeks
D: 12 to 20 weeks
E: 16 to 24 weeks

Recovery in adolescent depression
Up to what proportion of clinic referred cases
with moderate to severe depression will
recover within 2-4 weeks of assessment and
early intervention:
A: 1%
B: 5%
C: 10%
D: 20%
E: 40%

Standardised measures in child and
adolescent depression
Which of the following applies to the Mood and
Feelings Questionnaire:
A: It is clinician rated
B: It is a measure of impairment
C: It has only been validated in community
samples
D: There is a short and a long version
E: It screens for common co-morbidities


Age of onset and sex ratio tend to go
together
◦ Neurodevelopmental disorders characteristically
begin early in life and are much more common in
males

Emotional disorders beginning in adolescence
tend to be much more common in females
◦ E.g. Depression and eating disorders



In childhood rate of depression comparable in
boys and girls
Female predominance in mood disorders first
emerges in adolescence
Evidence to support view that depression in
adults has origins in adolescence

Depression much more common in
adolescents than in children
◦ Prevalence in pre-schoolers unknown
◦ 6-11 year olds, 12 month prevalence rates around
0.5-0.75%
◦ Rates increase with age, reaching 2-4% for 12-18
year olds
◦ 3-4 Year 11s (15/16-year-olds) out of group of
100 will have an episode of depression in any one
year period



Using ICD-10 criteria:
Approx. 50-60% of diagnosed cases in the
mild category
40-50% moderate to severe



Rates of underdiagnosis and undertreatment
higher in adolescents than in adults
ADAPT – at best 10–12% of all depressed
cases reach a specialist CAMHS per year
Treatment utilisation higher when
adolescents present with co-morbid
disorders



Associated with raised risk of suicide (odds
ratio 11 to 27)
Suicide represents 3rd leading cause of death
in this age group (aged 14-19 years)
Must ask about this during assessment

Why is this important?
Affects functional outcomes:
1.
o ↑ level associated social problems, academic
problems and global role impairment
Deleterious impact on:
2.
o
o
o
Duration of depressive symptoms
Response to treatment
Recurrence of depressive episodes

The rule for adolescents
◦ up to 90% comorbidity for at least one additional
disorder among moderate to severely depressed
adolescents attending routine services
Common:
◦
◦
◦
◦
◦
Disruptive behaviour disorders (20-40%)
Anxiety disorders (30-75%)
Eating disorders
Substance misuse
ADHD, PDD



20-50% have two or more comorbid
diagnoses
Some evidence depression in adolescence
emerges after comorbid disorder
Possible exception of substance abuse and
conduct problems
◦ ? Complication of depression
◦ May persist after episode remits

Pre-pubertal depression – probably 2 types;
1. Co-morbid behavioural problems, parental
criminality, parental substance misuse, family
discord – more common, without increased
recurrence risk into adulthood
2. Highly familial, multi-generational loading for
depression, high rates of anxiety and bipolar
disorder, recurrences of depression in
adolescence and adulthood



Adolescence - untreated episode median 7-9
months
Sub-group, ? 20–30% who untreated will have
disorders that may last years
Treatments bring forward onset of recovery
when compared to naturalistic outcomes by
perhaps 3–5 months

In specialist clinic referred cases with
moderate-severe depression:
◦ Up to 20% recover in the first 2–4 weeks of
assessment and early intervention
◦ Further 60% are likely to recover in the next 12–28
weeks of treatment
◦ Significant sub-group of treatment resistant cases –
in the region of 20%

Some evidence adolescents more at risk for
developing depression than in the past
Individuals born in latter part of 20th century
at greater risk for mild/moderate mood
disorders, manifesting at a younger age

Cumulative probability of recurrence:

◦ 40% by 2 years
◦ 70% by 5 years

Criteria in adolescents same as for adults
◦ DSM-IV allows irritability instead of depressed
mood in children and adolescents

Thus clinical questioning approach in
adolescents should be similar to that used in
adults

BUT primary presenting concern may be
different, i.e. vital to look past it
◦
◦
◦
◦
◦
◦

Behavioural problems
Substance misuse
Anxiety symptoms
School refusal
Academic failure
Unexplained physical symptoms
All significantly associated with adolescent
depression (reported odds ratios 10 to 29)
From CPD online module




Must see child/young person yourself
BUT helpful to question parent(s)/carer(s)
Check whether symptoms associated with
impairment
Consider use of standardised measures:
◦ MFQ – validated in clinic and community samples,
patient/parent-rated symptom scale, short and
long version
◦ CGAS – clinician-rated, measure of impairment





Mood disorder secondary to general medical
condition
Substance-induced mood disorder
Bereavement
Adjustment disorder
Bipolar affective disorder
Individual
factors
Family factors
Environmental
factors
Predisposing

PPH
Possible LD
Poor social
Individual LD,
factors
Possible early
network

parental
Family factors
misattunement

Precipitating
Sense offactors Mother’s
New school year
Environmental
responsibility for
admission to

Predisposing
admission
hospital

Maintaining
BMs
Mother’s mental
Social care input
LD, PPH Erratic
Adolescent desire
illness
declined

for independence
Tired father
Strained
Possible LD
Degree of role
working all the
relationship with

reversal
with mum time
school
Possible early
parental
misattunement
Brother with

Poor social network additional needs
Protective
Wanting help
Writes diary/draws
Committed father
School supportive
Close relationship
with TA
CAMHS gender ratios
Options:
 1:10
 1:6
 1:4
 1:2
 1:1
 2:1
 4:1
 6:1
 10:1
 Select the female to male ratios for the following conditions
A.
B.
C.
D.
E.
F.
G.
Autism
Asperger’s
Adolescent depression
Tourette’s syndrome
Child ADHD
Bulimia nervosa
Childhood (pre-13) depression

Gender ratios:
◦
◦
◦
◦
◦
◦
◦
Autism 1:4
Asperger’s 1:6
Adolescent depression 2:1
Tourette’s syndrome 1:4
Child ADHD 1:2
Bulimia nervosa 10:1
Childhood depression 1:1
Co-morbidity in adolescent depression
Co-morbidity among moderate to severely
depressed adolescents attending routine NHS
services reaches which of the following:
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%

Treatment in adolescent depression
Treatment of adolescent depression brings
forward onset of recovery when compared to
naturalistic outcomes by which of the
following:
A: 1 to 2 weeks
B: 2 to 6 weeks
C: 4 to 12 weeks
D: 12 to 20 weeks
E: 16 to 24 weeks

Recovery in adolescent depression
Up to what proportion of clinic referred cases
with moderate to severe depression will
recover within 2-4 weeks of assessment and
early intervention:
A: 1%
B: 5%
C: 10%
D: 20%
E: 40%

Standardised measures in child and
adolescent depression
Which of the following applies to the Mood and
Feelings Questionnaire:
A: It is clinician rated
B: It is a measure of impairment
C: It has only been validated in community
samples
D: There is a short and a long version
E: It screens for common co-morbidities





Rates of depression rise sharply after
puberty, especially in girls, with immediate
and long-term risks
Consider possibility of depression even when
child/adolescent does not present primarily
with mood symptoms
Adopt rigorous approach to assessment –
think developmentally
Carefully monitor suicidal risk



CPD online module on child and adolescent
depression authored by Raph Kelvin
Rutter’s Child and Adolescent Psychiatry,
Rutter et al
Major treatment trials (RCTs) for those
interested:
◦ TADS (The Treatment for Adolescents with
Depression Study)
◦ ADAPT (The Adolescent Depression
Antidepressant and Psychotherapy Trial)
◦ TORDIA (The Treatment of Resistant Depression
in Adolescents)