Depressive Disorders in Children and Adolescents: Identification and Treatment

1. Depressive Disorders in Children and Adolescents: Identification and Treatment Elizabeth McCauley, PHD, ABPP Professor University of Washington/Seattle Children’s Hospital

2. Agenda • What is Depression? • Scope of the Problem • Diagnostic Dilemmas • Causal Model: predisposing, precipitating, perpetuating • Adolescence as a Risk Factor • Assessment • Treatment

3. What is Depression?? • Major Depressive Disorder • Depressed Mood/Irritability and/or anhedonia • Presence of subset of other symptoms: sleep or appetite disturbance, morbid ideation/suicidality, decreased energy, difficulties concentrating/making decisions, hopelessness/down on self • Symptoms which occur together, persist for at least two weeks and are associated with a significant loss of ability to function • Other depressive dxs: Dysthymia, Adjustment Disorder with Depressed Mood • Mounting body of evidence suggest that depression differs from normal experience in degree, rather than in type (Coyne, 1994; Ruscio & Ruscio,2000, 2002). • Major depression appears to be a quantitative variation of normal functioning • Use of continuous versus categorical assessment approaches

4. What is Depression?? When is depression depression….? • Persistent vs. transient symptoms—79% persistence in recent study of 8th graders assessed via self-report in a school setting at 4 week intervals • Youth with subclinical symptoms at increased risk for subsequent depression, adverse outcomes • Experiencing a first episode of depression increases the likelihood of recurrence and continuation into adult life • Importance of assessing functional impairment

5. Depression: Scope of the Problem • Children: 1 year prevalence rate of 2% • Adolescents: 1 year prevalence rate of 4% to 8% • National Cormorbidity Survey: 6.1%, 15-24 years • Lifetime prevalence (up to age 18) 15%-20% • 65% of adolescents report some depressive symptoms • 5% to 10% of youth with subsyndromal symptoms have considerable psychosocial impairment, high family loading for depression, and an increased risk for suicide and developing MDD (Fergusson et al., 2005)

6. Scope of the Problem • Mean length of episodes: 7 to 9 months • 6% to 10% become protracted • Recurrence: 30 -50% • Approximately 20% develop bipolar disorder • Associated with significant: • comorbidity • functional impairment • risk for suicide • substance use

7. Diagnostic Dilemmas: Comorbidity • Depression • 40% to 90% have co-morbid dx; 50% 2+ -- Dysthymia and anxiety – 30% to 80% -- Disruptive Disorders – 10% to 80% -- Substance Abuse – 20% to 30% • Community-based study--43% of depressed youth had at least one other concurrent diagnosis, most commonly anxiety (18%). (Rhode, et al., 1994) • MDD presents after anxiety and disruptive dx: substance abuse 2nd to depression • Odds Ratios--Anx 8.2; Conduct and ODD 6.6; ADHD 5.5 times more common in depressed youth

8. Causal Model? Stress Diathesis Model • Diathesis—vulnerability • Biological—genetic, temperament • STRESS GENE ?? • Environment—loss, abuse, neglect, demoralization • Cognitive Style—negative cognitive style, see cup ½ empty, attribute failure to internal characteristics, success to chance, hopelessness

9. Increasing Prevalence of Depression in Adolescence Depressive Disorders: • Adults: 15-20% rates; 2:1 female to male • Age 11: Incidence low; males > females • Age 13: Incidence rising; males = females • Age 15, 18, 21: Incidence rising; males < females

10. Adolescent Development Development of overall rates of clinical depression (1-year point prevalence combining new cases and recurrences by age and gender) (Hankin, et al., 1998)

11. Why are Adolescents So Vulnerable?

12. Neurobehavioral Development in Adolescents Early Adolescence Puberty stimulates changes in brain systems regulating arousal and appetite that influence intensity of emotion and motivation Middle Adolescence adolescent emotional and behavioral problems 2nd to poor regulation skills--particularly when gap between pubertal arousal and consolidation of cognitive skills is extended Late Adolescence With age and experience comes maturation of frontal lobes which facilitates regulatory competence

13. Case Presentations • 14 year old male, first semester of high school, bout of the flu—never back to school on a regular basis, • Stressors: Significant growth spurt in 7-8th grade, move from family home, start of high school, loss of cat, family discord • Presentation: Inability to attend school, irritability, appearance of depressed mood, loss of interest in activities, social withdrawal, marked sleep disturbance, dec concentration

14. Case Presentations • 10 yr old girl with history of marked irritability and tendency to see “cup half empty” • 13 year old Chinese Am girl, sudden drop in grades with acute onset depressive sx • 17 yr old female, senior in high school, high achieving, family conflict, struggling to emancipate • 16 yr old boy, junior in high school, active in scouts, threatens peer at school, parental illness

15. Importance of Assessment • Assessment before making treatment plan • Assessment of changes in key symptoms/ behaviors during tx • Assessment of how things are going from family/youth’s persepctive

16. Assessment Tools Why Use: • Raise adolescent’s awareness of issue as a possible concern • Let adolescent know these issues can be brought up • Allow opening for educational intervention • Demonstrate concern

17. Depression Screening Scales • Patient Health Questionnaire for Adolescents (PHQ-A) • 5 minutes to complete, easy to score algorithms based on DSM-IV criteria for Major Depressive Disorder and Dysthymia • Algorithms for mental health comorbidities that might be seen in primary care (Generalized Anxiety Disorder, Panic Disorder, Substance Abuse or Dependence, Alcohol Abuse or Dependence, Nicotine Dependence, and Eating Disorders). • Children’s Depression Rating Scale (27) • Measures distress; clinical cut-off 20

18. Depression Screening Scales • Beck Depression Inventory for Primary Care (BDI-PC) • is a 9-item self-report measure of depressive symptoms, The primary care version has been shown to have high internal consistency, good concurrent validity in adolescent samples • Moods and Feelings Questionnaire (30) • Brief format—13; 11/8 clinical cut-off • Achenbach Youth Self-Report Form (103+) • Assesses social function, mood, anxiety, and behavioral problems www.ASEBA.org

19. Moods and Feelings (Angold et al.,1995) • I felt miserable or unhappy • I didn't enjoy anything at all • I felt so tired I just sat around and did nothing • I was very restless • I felt I was no good anymore • I cried a lot • I found it hard to think properly or concentrate • I hated myself • I felt I was a bad person • I felt lonely • I thought nobody really loved me • I thought I would never be as good as other kids • I did everything wrong 0-2 scale. clinical cutoff 11

20. Patient Health Questionnaire (PHQ-9) • Little interest or pleasure in doing things • Feeling down, depressed, or hopeless • Trouble falling/staying asleep, sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself – or that you are a failure or have let yourself or your family down • Trouble concentrating on things, such as reading the newspaper, watching TV • Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way 0-3 scale. Not at all to Nearly Every Day; 10-14 Moderate Dep

21. Assessment: Depression • Sorting out parent/youth conceptualization of the problem • Parent/youth’s sense of what treatment will be useful • Differential trajectories—hopelessness depression, age of onset, ADHD or other co-morbidities • Acute family problems--parental mental health concerns, abuse/neglect, derogation, reinforcement for illness behavior, cultural/generational conflicts, unresolved grief • School Issues--learning disability, attendance problems, harassment, isolation • Peer/partner issues--pregnancy, sexual pressure, break-ups, sexual orientation issues, loss of friends

22. Assessment and Case Conceptualization • Assessment before making treatment plan • Assessment of changes in key symptoms/ behaviors during tx • Ongoing assessment of issues to refine your case conceptualization

23. Anxiety Disorders Kendall’s Coping Cat; March’s OCD Tx Social Effective Tx-Beidel Exposure/Transfer of Control-Silverman Depression CBT—Clarke, Lewinsohn Interpersonal Psychotherapy--Mufson Behavioral Activation ADHD Family, social skills, attentional skills training ODD/CD Parent-child Interaction Therapy—Chamberlain The Incredible Years—Webster Stratton Parent/Child Treatment for Aggression—Barkley, Kazdin Case conceptualization Tx Choice

24. Depression: Treatment Issues Background and Rationale • Current tx response rates only 60-70% and high relapse within one year • Limitations of pharmacological options • Up to 40% are “non-responders” • 58-61% report bias against meds (Gray, 2003) • “Medicine might…change my personality, control my thoughts, not let me be myself” • Beliefs about efficacy and stigma • Concerns regarding potential increased risk of suicide in youth using antidepressant medication

25. Medications Issues • 3 to 8 fold increase in the use of antidepressants in children and adolescents from approx 1990-2000 (Zito, et al., 2002; Rushton, et al. 2001) • Efficacy: • Fluoxetine (Prozac) – efficacious • Up to 40% are “non-responders” • Resistance/Adherence: Adolescent Attitudes (Gray, 2003) • 69% stopped taking meds by end of 4 weeks • 58-61% report bias against meds • “Medicine might…change my personality, control my thoughts, not let me be myself” • Issues around belief in efficacy of meds and stigma about MI

26. Duration of Antidepressant Use Richardson, DiGiuseppe, Christakis, McCauley, Katon, 2004.

27. Psychotherapy for Depression: Evidence of Treatment Effects Weisz, McCarty & Valeri 35 Trials Inc. TADS N=439 IPT- 2 trials ES = .34 (0.40 ULS)* Reinecke, Ryan & DuBois 6 CBT Trials ES = 1.02 (0.97) Lewinsohn & Clarke 12 Trials ES = 1.27 Michael & Crowley 14 Trials ES = .72 1998 1999 2002 2006 Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149 * Unweighted least squares

28. 2007 Adjusted mean Children's Depression Rating Scale-Revised (CDRS-R) total scores The TADS Team, Arch Gen Psychiatry 2007;64:1132-1143.

29. Moving on with Treatment CBT-the most widely investigated psychotherapy for depression “You can change how you feel by changing how you think” • CBT Draws on 4 core sets of strategies: • Facilitative • Behavioral Activation • Automatic Thoughts • Core Beliefs Aaron T. Beck Require ability to reflect on, monitor, and evaluate own thinking process in midst of heightened emotional arousal—may not have skills on board

30. Moving on to Treatment—What Works Best? Principles of CBT: Philosophy • Collaborative Model • Structured Sessions • Blend Didactic, Directive, & Socratic Questioning • Ongoing Assessment (inc. regular feedback) • Effect Change in Thought, Affect, & Behavior • Relapse Prevention

31. Principles of CBT: Technology • Agenda Setting • Mood Monitoring • Behavioral Activation; Structuring Activities • The ABC’s of CBT: Linking Affect, Behavior, & Cognition • Thought Records & Changing Beliefs • Cognitive-Behavioral Case Conceptualization • Becoming Your Own Therapist

32. Getting Started: Assessment, Feedback, & Treatment Plan Example: 15-year-old girl (Kelly) presenting with depressed affect, loss of interest, sleep and concentration problems, and low self-esteem. Chief complaints are sadness, social isolation, and slipping grades. Maternal history of depression and substance use, absent father, limited family/social support. Endorses suicidal ideation; no plan. Provide feedback and psychoeducation re: depression and appropriate treatment, discuss role of pharmacotherapy and psychotherapy, establish treatment plan including course of CBT.

33. Initial Sessions: • Agenda Setting (organize session & model effective strategy) • Mood Monitoring (highlight highs and lows) • Activity Scheduling (behavioral activation to improve mood, increase social exposure) • Continue building rapport (validate, praise, model optimism) • Ongoing case conceptualization

34. Middle Sessions: • The ABC’s of CBT: Linking Affect, Behavior, & Cognition • What was the situation? • What were you thinking? • How were you feeling? • What did you do? • Thought Records

35. Supplementary Materials…

36. Middle Sessions: • The ABC’s of CBT: Linking Affect, Behavior, & Cognition • What was the situation? • What were you thinking? • How were you feeling? • What did you do? • Thought Records • Using Thought Records in Ongoing Case Conceptualization

37. Middle Sessions: • Cognitive Restructuring: • Validation • Downward Arrow • Evidence Testing Automatic Thoughts  Underlying Beliefs

38. Middle Sessions: • Cognitive Restructuring: • Validation • Downward Arrow • Evidence Testing • Using Cognitive Restructuring in Case Conceptualization

39. Final Sessions: • Relapse Prevention: ‘Becoming Your Own Therapist’ • Termination

40. Core Principles of Interpersonal Psychotherapy • Link between mood and life events • Focused, time limited treatment • “Here and Now” treatment • Medical Model • Active Therapist

41. General IPT techniques • Supportive listening • Optimistic stance • Encouragement of affect • Eliciting details • Exploring options • Role playing • Communication analysis • Use of the therapeutic relationship

42. Initial Phase (sessions 1-4) • Conduct psychiatric interview, assess symptoms, diagnose, offer the sick role • Conduct Interpersonal Inventory • Select interpersonal problem area as patient’s treatment focus • Provide patient with an interpersonal case formulation

43. Interpersonal Inventory • Ask about significant people in the adolescent’s life (family, friends, mentors) • Start with the basics • Frequency of interactions • What do they do together? • Expectations for the relationship • Were they fulfilled? • What changes does the adolescent want to make in the relationship • Has the adolescent tried to make changes already? • What worked or didn’t work? • How has depression affected the relationship?

44. Life Events Associated with the Depression • Probe for: • Changes in family structure • Changes in school • Moves • Death, illness, accident, or trauma • Onset of sexuality and sexual relationships • Establish a time frame and sequence of events relating to the depression

45. Common Developmental Issues for Adolescents • Separation from parents • Exploration of authority in relation to parents • Development of dyadic interpersonal relationships with members of the opposite sex • Initial experience with death of a relative or friend • Peer pressure

46. Interpersonal Problem Areas • Grief • Interpersonal disputes • Role transitions • Single-parent family situations • Interpersonal deficits

47. Strategies for Treating Interpersonal Disputes • Focus on the adolescent’s expectations for the relationship • Are they realistic? • How do they differ from expectations of others? • How has teen tried to resolve the dispute? • Explore communication patterns that may be complicating the resolution of dispute • Help the teen gain perspective on what has occurred in the relationship • Help the teen find strategies for coping with unreasonable expectations of the parent and the feelings of anger/sadness engendered

48. Communication Analysis • Goal is to teach the adolescent to communicate in a more effective manner through: • Clarity • Directness • 5 categories of ineffective communication • Ambiguous and/or nonverbal communication instead of open confrontation • Holding incorrect assumptions • Using unnecessarily indirect verbal communication • Using “the silent treatment” and closing off communication • Using hostile communication

49. Communication Analysis (II) • Help the adolescent to understand • The impact of his/her words on others • The feelings he conveys with verbal and nonverbal communication • The feelings that generated the verbal exchange • Teach alternative communication strategies • How to communicate feelings and opinions directly • Using empathy • Understanding the other person’s perspective --“putting yourself in other person’s shoes”

50. Treatment Strategies for Role Transitions • Mourn the loss of the old role and accept the new one or find an alternative role • Examine the positive and negative aspects of old role, what adolescent is afraid will be lost, and the teen’s perception of new role • Educate parents about the role transition • Develop social skills to help teen to successfully negotiate the transition • Help adolescent generate opportunities to increase social support