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Child and Adolescent Depression

Child and Adolescent Depression. Dr. Anahit Gasparyan Consultant in Child and Adolescent Psychiatry Wansbeck Hospital. Depression. Major depressive disorder Dysthymia Adjustment disorder with depressed mood Within 1 to 3 months, no more 6 Bipolar disorder Suicide and self harm. History.

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Child and Adolescent Depression

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  1. Child and Adolescent Depression Dr. Anahit Gasparyan Consultant in Child and Adolescent Psychiatry Wansbeck Hospital

  2. Depression • Major depressive disorder • Dysthymia • Adjustment disorder with depressed mood • Within 1 to 3 months, no more 6 • Bipolar disorder • Suicide and self harm

  3. History • Rufus of Ephesus, Gr. physician,A.D. 2 • Melancholia - in adolescents, infants and young boys • R. Burton- “Anatomy of Melancholy”, 1621 • Education, parenting, inherited • H. Maudsley,1867 - melancholia - one of the 7 forms of childhood insanity • Arnold, 1782 - nostalgic insanity in young people

  4. History • C 18th, Europe - references to affective disorder in children and adolescents • C 20th - gradual recognition of depression in C&A as nosological category • Depression as “adolescent turmoil” prior to 1970s and 1980s • Pre-adolescent - incapable of D.

  5. Major Depressive Episode: DSM-IV • 5 or >symptoms, 2/52 duration, change from previous functioning depressed mood loss of interest or pleasure weight/appetite loss/gain sleep disturbance psychomotor retardation/agitation fatigue worthlessness/guilt low concentration suicidal ideas

  6. Major Depressive Disorder • Mild • Moderate • Severe • With/without psychosis • Single/recurrent • Mixed

  7. Dysthymic Disorder • Depressed mood for at least 1 year • Presence of 2 or > depressive symptoms • Never free of symptoms for >than 2 months at a time • Can have distinct episodes of depression - Double Depression

  8. Adjustment Disorder with Depressed Mood • Symptoms occur within 1 (ICD-10) to 3 months of stressor • Distress in excess of expected or • Impairment in functioning • Symptoms do not persist for more than 6 months after stressor stops • Does not meet criteria for other Axis 1

  9. Major Depressive DisorderDSM IV • Luby and colleagues (2002) proposed modified criteria for C&A depression • Sad/irritable mood, anhedonia, low energy, eating/sleeping problems, low self-esteem - prominent symptoms • Depressed/irritable mood must be present not persistent over 2- week • Persistent death/suicide themes in play for assessment of suicidal ideation

  10. Depressive DisorderICD-10 • Depressed mood, loss of interest and enjoyment, reduced energy- 2x • Reduced concentration, attention • Reduced self-esteem, self-confidence • Ideas of guilt and unworthiness • Pessimistic view of future • Ideas/acts of s/h or suicide • Sleep problems • Diminished appetite

  11. Problems with Classification • Depressive symptoms are common in adolescence. • Depressive disorder should only be diagnosed in: • significant impairment of social functioning • symptoms disabling, causing sign. suffering • severe suicidality present

  12. Aethiology of Early- Onset Depression • Atypical early epigenesis- first few years • Leads to formation of vulnerable neuronal network incorporates amygdala and VPC resulting in impaired mood regulation • Acquired neuroendangerement: reduced synaptic plasticity in hippocampus, NA and ventral tegmentum

  13. Aethiology of Early- Onset Depression. • Leads to motivational, cognitive , behavioural deficits throughout the life span • Early depression can be caused by a triadic interplay between trophic, sertonergic and corticoid systems in early development that influence the tonic regulation of HPA axis, amygdala and VPC (Goodyer I, 2008)

  14. Comorbidity • Conduct disorders- 40% (DSM) • Anxiety disorders- 34%: GAD and social phobia in A, separation anxiety disorder in C • Dysthymia-DD, 30-80% • Substance misuse

  15. Epidemiology and Course • Children- MDD 2.1%, M=F, 4-5y.o. >2-3 • Adolescents- MDD 4-8%,M:F- 1:2 • Population studies revealed: at any given time 10-15 % of C&A reported depressive symptoms • By the age of 18- 20-25% - depressive episode

  16. Course • Worse longitudinal course: • Female sex • Increased guilt • Previous episode of depression • Parental psychopathology Duration of first episode: children - 8-13/12 Rate of recovery 90%, 30-70% relapses/recurrences

  17. Course • High rates of recurrence: 20-60% in 1-2 years post-remission • 70% after 5 years (G. Milavic, 2009) • In clinical samples average duration MDD episode: 32/52 • DD-up to 3 years (Chrishman, et.al. 2006)

  18. Course • Duration of first episode in adolescents: 3-9/12 • Rate of recovery: 50-90% • Relapses: 20-54% • Factors predicting greater recurrence: • Older age of 1 episode • Female sex • Fathers MDD

  19. Course • Longitudinal predictors of depression/anxiety in 10 year olds: • Lower IQ • Attention/concentration problems • Prenatal marijuana exposure • Household density • Early childhood injuries

  20. Symptoms of Depression • Low mood (with loss of enjoyment- anhedonia and loss of concentration) • Biological symptoms (somatic syndrome) • Depressive (negative cognitions) of self, others and future • Suicidal ideation and acts • Psychomotor retardation/agitation • Delusions of worthlessness, guilt

  21. Depression in Different Age Groups • In children (prepubescent group): • Withdrawn/inhibited temperament and irritability are associated with depression • Maternal depression is associated • Less likely to have FHx depression • Genetic factors are less important than in adolescent depression

  22. Depression in Different Age Groups • In children (prepubescant group): • Sleep and appetite problems less common • Guilt and hopelessness less common • More somatic complaints (tummy and headaches) • Psychomotor agitation • Separation anxiety/ phobias • Suicidal plans less lethal • Anhedonia- highly specific marker of putative melancholic subtype

  23. Developmental Caveats in Diagnosing Depression • Cognitive immaturity • May not be able to verbalise depressive ideation, express irritability and frustration - temper tantrums • Emotional immaturity, leading to externalizing distress through behavioral problems(fighting)

  24. Depression in Different Age Groups • Postpubertal presentation is similar to adult • Increased risk of suicide in adolescents: ODDs ratio: 11to 27 • Suicide is 3rd leading cause of death in 14-19 year old (Thapar et. al. 2010)

  25. Depression in Different Age Groups • Substance abuse • Problematic interpersonal • Relathionships • Documented trend towards generational increase of depression • Significant continuity into adult life

  26. Clinical Variants • Psychotic depression • Bipolar disorder • Seasonal affective disorder • Subclinical depression • Atypical depression • Treatment resistant depression

  27. Differential Diagnoses • Normal sadness (grief reaction) • Misery • Non-affective psychiatric disorders: anxiety disorders, LD, disruptive behavioral disorders (ADHD, ODD) • Anorexia Nervosa with depressive affect

  28. Differential Diagnoses • Adjustment disorder with depressed mood • Chronic fatigue syndrome • General medical conditions • Drug and alcohol misuse

  29. Risk Factors • Gender • Genetic loading • Lower IQ • Early adverse experiences/prenatal exposure • Concurrent psychopathology • Temperament/personality • Negative life events • Family environment/parenting

  30. Risk factors • Coping/cognitive styles • Problem-solving skills • Biological factors • Household density • Social isolation • Ethnicity

  31. Assessment of Depression in C&A • Caregiver’s/parents’ info • Child’s view, info, story, play, drawing • Collateral info from school,GP, siblings, other family members • Diagnostic assessments tools (SDQ, CDI, BDI, PAPA, Dominic Interactive) • Risk assessment (MSE the least) • Non directive play therapy

  32. Treatment • Psychotherapy • CBT • IPT • Family therapy • Psychodynamic • Pharmacotherapy • Psychoeducation

  33. Treatment Guidelines • NICE, Sept. 2005 • Mild D. (5DSM-IV Sx, HAM-D >12-17)- tier 1/2,watchful waiting,psychotherapy • Moderate D.(6DSM-IV Sx, HAM-D >18-24)- tier 2/3, specific psychotherapy, after -4-6 sessions, add antidepressant • Severe D. (8DSM-IV Sx, HAM-D >24)- tier 2/3/4 start with psychotherapy and fluoxetine

  34. Medication • First-line treatment: • SSRI-fluoxetine, in 12-18, in 5-11- cautious consideration Second-line: Sertraline, citalopram Do not prescribe: paroxetine, venlafaxine, St.Jon’s wort

  35. Treatment- Children • Evidence base for medication is only for fluoxetine • Most of the studies done in adults and youth and extrapolated to children • Family and environmental changes often could be beneficial • Contextual Emotion-Regulation Therapy-new, developmentally suitable intervention for children;pilot study; self-regulation of dysphoria

  36. Treatment • Depression Experience Journal • Computer based intervention for families with C&A with depression • Psychoeducational therapy based on a narrative model • Sharing personal stories of depression • Encompasses narrative therapy, social support, preventive intervention

  37. Treatment • TADS: CBT no better than placebo • CBT&fluoxetine: beneficial, response rate:- 71% • Fluoxetine only- 61% (Thapar et al. 2010), acceptable benefit to risk ratio • TCA, venlafaxine, paroxetine- low (Milavic, 2009) • Medication after 4-6/52 of psychological therapy in moderate/severe MDD

  38. Prognosis • Mean duration episode MDD 6-9/12 • 70-80% recover by 9/12-12/12 • 10% remain chronically depressed • Relapse/recurrence- common • Recurrence -50% within 3-5 years

  39. Prognosis MDD • Childhood onset • Increased relapses, severity, increased rates of anxiety • Risk of suicide, bipolar disorder, substance misuse • Better prognosis • Postpubertal • Risk of suicide, self-harm, substance use, poor psychosocial functioning in adult life • Boys are at greater risk of persistent depression

  40. Prognosis - Dysthymia • Persistent course • High risk of depression (DD), often in about 2 years after initial diagnosis • Can be difficult to diagnose • Comorbidity affects the outcome (e.g. conduct disorder)

  41. Deliberate Self-Harm • Rare in childhood • Boys>girls in <12 year olds • In adolescents about 100 times more common than suicide • Girls>boys 3:2 community,5:1 clinic • Self-poisoning (OD) most common • Clear precipitant • Depression less likely (adults-40%)

  42. DSH • 15-25% repeat attempts, 10% within the next year • 1% will kill themselves within 2 years • Self harm can be cry for help • Thorough assessment of first presentation is paramount • May help to prevent future attempts

  43. Suicide • Suicidal ideation is common in adolescence • Completed suicide is more common in men • Surveys in US, CDC, 2000, revealed: • 8-9% suicide attempt rate • 2-3% - medical help • 27% 17 year olds thought about suicide in 12/12 • 16% made plan

  44. Critique • Comments on NICE by Dr. P.McArdle, 2007 • There is no large enough number of RCTs in C&A population • Role of the clinical experience • The overall evidence of effectiveness is inconclusive • Complex comorbidities: loss of CBT superiority > TAU in 6/12

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