Depression in Adolescence Topics To Be Covered What is depression? Prevalence in adolescence – Gender differences – Course of depression What causes depression? How do we.
Download ReportTranscript Depression in Adolescence Topics To Be Covered What is depression? Prevalence in adolescence – Gender differences – Course of depression What causes depression? How do we.
Slide 1
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 2
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 3
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 4
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 5
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 6
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 7
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 8
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 9
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 10
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 11
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 12
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 13
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 14
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 15
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 16
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 17
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 18
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 19
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 20
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 21
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 22
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 23
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 2
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 3
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 4
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 5
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 6
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 7
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 8
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 9
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 10
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 11
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 12
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 13
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 14
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 15
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 16
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 17
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 18
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 19
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 20
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 21
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 22
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).
Slide 23
Depression in
Adolescence
Topics To Be Covered
What is depression?
Prevalence in adolescence
– Gender differences
– Course of depression
What causes depression?
How do we treat depression?
Can we prevent depression?
What is Depression?
DSM-IV Criteria for Major Depressive
Disorder
Unique Features for Children/Teens
Dysthymic Disorder
Diagnosis versus Depressed Mood
versus Depressive Syndrome
DSM-IV Major Depressive Episode
Persistent sad or irritable mood
Loss of interest in activities
Significant change in appetite or weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Worthlessness or excessive guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Common Manifestations in
Adolescence
Frequent physical complaints--headaches,
muscle aches, stomach aches, tired
Frequent absences from school, poor
performance in school
Talk about or try to run away from home
Shouting, complaining, irritability or crying for
no reason
Alcohol or substance abuse
Rumination
Being bored, lack of interest in friends
Dysthymic Disorder
Depressed or irritable most of the day, more days than not, for at
least 1 year
Plus, at least 2 of the following:
– eating problems
– sleep problems
– low energy
– low self-esteem
– poor concentration/decision making
– Hopelessness
Onset typically in childhood or adolescence
Average duration in children/adolesc ~4 years
70% of those with dysthymia eventually develop Major
Depressive episode
Prevalence of Depression in Adolescence
Major Depressive Disorder: 4.9% (of 917 year olds, from MECA study)
Depressed Mood:
– Parents’ reports: approx. 15%
– Adolescent reports: 25-30%
Gender Differences in Depression
Through age 12, no gender difference
(or males slightly higher)
After age 12, girls more likely than boys
to have depressive disorders, and
depressed mood.
Difference: Girls 2 - 3x more depression
than boys.
Why Gender Differences?
Differences in risk factors/stresses for girls,
e.g., assertiveness, ruminative coping style,
body image stresses?
Course of Depressive Illness
•
Depression is episodic. However, most
youth experience a recurrence.
•
20 - 40% relapse within 2 years
•
70% relapse by adulthood
What Causes Depression?
Family History Factors
Family History of Depression
– Between 20-50% of adolescents with
depression have a family history of it
– Children of depressed parents are 3x more
likely to develop a depressive disorder
Could be due to genetic factors, and/or
environmental
– Parents may be unavailable, dysfunctional
interactions with child, family conflict.
Biological Factors
Most work has been done with adults, little
with adolescents or children.
Serotonin levels have been linked to
depression in adults
Pituitary functions--increased cortisol and
hypo- or hyperthyroidism--linked to adult
depression (Implicated in vegitative
symptoms, i.e., eating, sleeping)
Cognitive Factors
Pessimistic attributional bias
– Person assumes blame for bad events
– Overgeneralizes from one bad experience
to a pattern (everthing I do is wrong)
– Believes problems will persist permanently
(Nothing will make it better)
Unclear whether this bias precedes
depression, occurs simultaneously, or is a
result of it. Once developed, the style tends to
endure, possibly increasing the risk of future
episodes.
Peers
Low peer popularity, rejection by peer
groups
Lack of closeness with a best friend
Fewer supportive social relationships
Daily and Stressful Life Events
Bruce E. Compas
Confluence of puberty
and school change
Depressed adolescents
report both more acute
and more chronic
stressors than youth
with antisocial disorders,
medical problems, or
normal controls.
Interventions for Youth
Depression
Psychosocial and Psychotherapeutic
Cognitive Behavioral, Psychodynamic,
Family, and Supportive Group Therapy all
shown to improve depressed mood
Most rigorous study was with Cognitive
Behavioral Therapy
– Showed 50% reduction in rate of Major
Depression in treatment group, relative to
untreated
– Focus on cognitive distortions, generating ‘rational’
alternatives, positive events
Medication
Tricyclic anti-depressants were never shown
to be effective with kids/teens
Currently, SSRI’s used.
– First tested was fluoxetine. 56% improved
significantly (31% completely), versus 33%
controls (23% completely). More effective than
impramine (a tricyclic)
– In the large study TADS study (Treatment for
Adolescents with Depression), combination of
fluoxetine plus cognitive behavior therapy superior
to either alone (next slide).
Medication c’t’d
The relative large gap between placebo & medication
in previous slide is unusual in the literature
– E.g., 2003 JAMA study of sertraline in 400 youths (K.D.
Wagner et al.), 69% improved on medication vs. 59%
placebo. Statistically significant, but sertraline made a
difference only in ~10% of youth.
Negative results do not get published
– E.g., 1 published study shows effectiveness of paroxetine.
However, 2 large unpublished studies found no effects, and
twice the risk of suicidal ideation.
– 2 large trials of venlafaxine show it to be ineffective with
adolescents, both unpublished.
Suicidal Symptoms in “TADS” study
Suicidal ideation
dropped fluoxetine
group as well as all
others.
But, 15/216 (6.94%) on
fluoxetine exhibited
suicidal behavior (e.g.
attempt or threat), vs.
9/223 on placebo
FDA Warning on Suicide &
antidepressant medications
“Black box” warning required for all SSRI and
tricyclic antidepressants.
In the FDA review, no completed suicides
occurred among nearly 2,200 children treated
with SSRI medications; however, the rate of
suicidal thinking or behavior, including actual
suicidal attempts, was 4 percent for those on
SSRI medications, twice the rate of those on
inert placebo pills (2 percent).