YOUTH HEALTH 2011 Depression and Suicide in Teenagers: an overview and update

1. YOUTH HEALTH 2011Depression and Suicide in Teenagers: an overview and update Professor Garry Walter Chair of Child and Adolescent Psychiatry, University of Sydney Clinical Director, CAMHS, Northern Sydney Central Coast Health Districts Editor, Australasian Psychiatry

3. Leah’s Story (from “Navigating Teenage Depression”) I was 16 when I was diagnosed … although in hindsight it started much earlier. I remember crying myself to sleep when I was about 9 years old, engulfed in a terrible grief I couldn’t comprehend, let alone explain. … It had always been a daily struggle for mum to get me to go to school, just as it was a daily struggle for me to stay home. I felt 10 years older than my peers and isolated from my teachers. I felt as if I knew terrible truths about the world they would never understand.

4. Leah’s Story Mum spent a lot of time in hospital after her first nervous breakdown. We coped with her bipolar disorder as best we could … Despite the truth of my own condition playing out in front of me, I still came to believe I was the way I was simply because I was a bad person. A lazy person. A stupid person. I may have felt I was carrying the heavy heart of someone twice my age .. But I was still just a kid. For the past few years, I found comfort where I could. I daydreamed at every opportunity … It’s much easier to be brave when faced with a fire-breathing dragon than with your own demons.

5. Leah’s Story I sought quick fixes in food and snacking became synonymous with being warm and safe … The bullying that began slowly and subtly in primary school continued and intensified throughout high school. I haven’t ever discussed the bullying with my family, nor with my teachers. My peers taught me about how I deserved to be treated and I became my own worst bully In high school.

6. Leah’s Story The years became a blur, a mess of raw emotion. In year 10 … things were just not right with me. I changed schools twice, a friend of mine committed suicide, my grandmother died, my final year exam was disastrous … I had no aspirations, no expectations of the future, no plans. I held on tightly to my last sliver of hope that things could only get better.

7. How common is a story like Leah’s? How typical are her features? Is Leah, like her friend, at risk of seriously harming herself? Could she be helped in some way?

8. Outline DEPRESSION • Frequency • Types of depressive illness • Reasons for lack of recognition • Clinical features • “Comorbidity” • Risk factors • Course • Bipolar Disorder • Assessment and treatment • The role of medication SUICIDE • Rates • Risk factors • Behaviours that may herald suicide • Assessment

9. Contains information about children’s health, development and wellbeing “It is estimated that as many as 20% of children in modern societies are affected by mental health problems and, in Australia, mental health problems and disorders as a broad group account for the highest burden of disease among children”

10. And what about depression?

11. Facts and Figures • Up to 40% of teenagers manifest depressive symptoms in any 6-month period • The “point prevalence” of depressive illness in teenagers is about 3% • The “lifetime prevalence” of depressive illness in teenagers is 4-24% • The rate of teenage depressive illness in Western societies may be increasing • Females: males ~ 2:1

12. Terminology: an important distinction • “Depressive symptoms” may be fleeting and/or part of a depressive illness • “Depressive illness” (or “disorder” or “syndrome” or “episode”) implies that the symptoms are of sufficient severity and duration to cause distress and/or dysfunction (not coping)

13. Types of depressive illness in teenagers • Major Depressive Disorder (“Major Depression”): the symptoms and signs are of least 2 weeks’ duration • Dysthymic Disorder (“Dysthymia”): generally less severe than major depression and persists for more than 12 months • Adjustment Disorder with Depressed Mood: the symptoms occur within 3 weeks of a stressful event • Mood Disorder due to a General Medical Condition: eg glandular fever, diabetes, neurological disorders • Substance-induced Mood Disorder: may result from alcohol or substance abuse or certain medications (eg steroids)

14. Major Depression is not typically part of bereavement, mourning or grief- these are “normal” events

15. … though these events may be complicated and made worse by Major Depression

16. “Houston, we have a problem” • At least 70% of teenagers with major depression do not receive appropriate diagnosis and treatment … why?

17. Reasons for the lack of recognition of adolescent depression • The old idea that some degree of “adolescent turmoil” is necessary for healthy development • The related belief that adolescents are robust and will “ride out” depression • The view that adolescent woes are trivial compared to the problems faced by adults in today’s world • The reluctance of many adolescents to seek help from authority figures like adults • Parents’ and teachers’ lack of specific knowledge about adolescent depression and its management

19. Reasons for the lack of recognition of adolescent depression • The old idea that some degree of “adolescent turmoil” is necessary for healthy development • The related belief that adolescents are robust and will “ride out” depression • The view that adolescent woes are trivial compared to the problems faced by adults in today’s world • The reluctance of many adolescents to seek help from authority figures like adults • Parents’ and teachers’ lack of specific knowledge about adolescent depression and its management

20. So what are the features? Essentially the same as depression in adults: • Depressed mood – seem unhappy, tearful, down in the dumps, or complain of sadness, emptiness • Negative thoughts about themselves – feel worthless, guilty • Loss of interest and pleasure in activities • Can’t think, concentrate, make decisions • Decline in level of functioning

21. But there can be differences • Depressed adolescents don’t always appear, or say, that they are sad • They may appear cranky, irritable, short tempered • Extended sleep (“hypersomnia”) is common • Appetite loss and decreased energy are less common • “Psychomotor change” (agitation or slowing down) is less common

22. Psychotic Depression • Depression in its most extreme form • The depression is accompanied by depressive delusional beliefs (“I am riddled with cancer and will die”) and/or hallucinations (commonly, critical voices inside one’s head, eg “You are an evil person, you deserve to be put down”)

23. Questionnaires can aid diagnosis and estimation of severity

24. “Comorbidity”

25. “Comorbidity” • There is increasing recognition that psychiatric disorders often co-exist • The medical term for the co-existence of 2 or more disorders in an individual is “comorbidity” • Comorbidity is much more common in children and adolescents than in adults • One study found up to two thirds of teenagers with major depression have another diagnosis • Depressed teenagers may also have: anxiety disorders, eating disorders, ADHD or other behaviour disorders, developing personality disorders etc

26. Risk factors: confirmed or probable • Older versus younger adolescents • Being female • Having a parent or other close biological relative with depression • Having an episode of depression earlier in life • Exposure to stressful life events

27. Risk factors: possible • Poor self esteem • Parental marital conflict • Uncaring or overcontrolling parenting style • Poor peer relationships • Learning difficulties • Coexisting medical problems

28. Precise cause is unknown, but a combination of nature (genes) and nurture (environment)

29. Natural course of depression

30. Course • Symptoms of major depression usually emerge over weeks • The established depressive episode typically lasts 6-8 months • 20% continue to be depressed after a year • 10% remain depressed at 2 years • 50% of adolescents will have 1 or more recurrences during their life • Long term, may impact on self-esteem, relationships, employment.

31. Bipolar disorder

33. Bipolar disorder • A small but not insignificant proportion of teenagers (~10%) who have major depression will go on to develop bipolar disorder (manic depressive illness) • One study suggested that the likelihood of bipolar disorder in depressed teenagers was increased by: • sudden onset of the depression • depression with psychotic features (delusions and hallucinations) • a family history of manic depressive illness • the emergence of manic symptoms if the depressed adolescent was treated with antidepressants

34. This is not a talk focusing on assessment or treatment, but …

35. Key elements of assessment Engagement Where possible, interview of adolescent, parent(s) and both Risk assessment Rating scales (e.g. CESD) Making a diagnosis Comorbidity screen Medical screen

36. Key elements of treatment “Psychoeducation” Developing a safety plan Therapy: problem-solving approaches for mild-moderate cases (specialist services may use “cognitive behaviour therapy” (CBT), other specific therapies) Medication for moderate and severe cases (helpful in 60%) Hospitalisation for very severe cases

37. 2011 NHMRC/beyondblue guidelines • Cognitive behavioural interventions should be considered for short-term symptom reductionin adolescents with identified depressive symptoms who do not meet diagnostic criteria for major depressive disorder. • Cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT) should be considered as first-line treatment for adolescents with major depressive disorder. • (B grade recommendations: “Body of evidence can be trusted to guide practice in most situations”)

38. The use of computerized self-help packages to treat adolescent depression and anxietyJournal of Technology in Human Services, July, 2010 • 38 participants • Compared face-to-face CBT, online CBT, combined face-to-face/online CBT, and control. • Combined face-to-face/online CBT is most effective • For those unable to access face-to-face therapy, computerized therapy may be a viable option.

39. “I read something about antidepressant medication … that’s right, doesn’t it increase the risk of suicide in a young person?”

40. “Isn’t it poison?”

43. Weight of evidence: state of play • Against the most commonly used antidepressants – selective serotonin reuptake inhibitors (SSRIs) – being associated with increased suicide in the young • Consistent with most young people who die of suicide not having the potential benefit of antidepressants at the time of their death

44. 2011 NHMRC/beyondblue guidelines • Young people should be monitored for the onset of or increase in suicidal thinking following initiation of SSRIs. (B grade recommendation)

46. 3 big recent US studies • TADS(Treatment for Adolescents with Depression Study) • TORDIA(Treatment of Resistant Depression in Adolescents) • TASA (Treatment of Adolescent Suicide Attempters)

47. “TADS” (Treatment for Adolescents with Depression Study) • “Much improved” at 18 wks: CBT 41%, fluoxetine 61%, combination 71% “TORDIA” (Treatment of Resistant Depression in Adolescents) • 39% on medication or medication + CBT achieved remissionby 6 months • Eventual remission evident within the first 6 weeks in many

48. 2011 NHMRC/beyondblue guidelines • Fluoxetineshould be considered for acute, short-term reduction of depressive symptoms in adolescents with moderate to severe major depressive disorder, where psychological therapy has not been effective, is not available or is refused, or if symptoms are severe. • CBT may be added to/continued with SSRI, to reduce the risk of suicidal thinking and improve functioning in adolescents with major depressive disorder. (B grade recommendations)

49. Other physical treatments

50. Transcranial Magnetic Stimulation