Depression and Anxiety:Two Sides of the Serotonin Coin

Successful Students IIIDr. Tim Johanson

Metropolitan Pediatric Specialists

Parenting Thoughts:

• Parental guilt

• Parental fear

• Parental hopelessness

• Parental frustration

Love Must Evolve

• In order for kids to become young adults, a parent’s love must evolve over time

• Infant: adored and protected teen/young adult: free and equipped

• When your kid falls behind, don’t panic…

Depression

• Unipolar: MDD (major depressive disorder)

• Dysthymia: chronic mild-moderate depression

• Bipolar Disorder: manic depressive disorder

Increased risk for:

• Illness, both real and psychosomatic

• Interpersonal difficulties

• Academic problems

Scope of Childhood Depression

• 2.5% children before teen years

• 8.3% adolescents age 13-19

• Female : male is 70:30

• Childhood depression often predicts depression in adulthood

Depression-Suicide Link

• 3rd most common cause of death in 15-24 year olds

• 4th most common cause of death in 10-14 year olds

• Triggers that lead to feelings of hopelessness, feeling trapped, unable to handle life anymore

• Believe suicide is the only way to solve their problems, a welcome escape

Signs of Possible Attempt:• Talks about death and/or suicide • Plans ways to kill him or herself• Expresses worries that nobody cares• Has attempted suicide in the past• Dramatic changes in personality • Withdraws from interacting with friends/family• Shows signs of a substance abuse problem• Begins to act recklessly • Begins to give away sentimental possessions• Spends time online interacting with people who

glamorize suicide

Diagnosis in Children…Difficult

• Signs/symptoms change with developmental ages of children and teens

• Kids have a harder time identifying and expressing their internal emotions

• For teens, adults in their lives are actually less likely to identify depression in them than the teen themselves (less connected, blame on other factors like hormones, etc)

Symptoms of Depression

• Persistent sadness• Irritable mood or agitation• Loss of interest, loss of energy• Excessive tiredness or inability to sleep• Feeling of worthlessness• Inappropriate guilt• Difficulty concentrating• Recurrent thoughts of death or suicide

DSM-4

• MDD (Major Depressive Disorder) if 5 or more symptoms are present for greater than two weeks

Signs of Depression

• Frequent school absences• Hear them talk about running away• Drug and alcohol use/abuse• Engaging in reckless behavior• Change toward extreme withdrawl

Triggers

• Stress, bereavement, loss, break-ups, abuse, neglect, trauma including natural disasters

• Usually, if depression has an identifiable trigger, counseling is the most effective way to manage it.

Parenting Thought:

• Life is difficult• Our child’s greatest opportunity to grow and

mature usually involves adversity• Parents should embrace things that may be on

the “checklist to adulthood” • Attitude of a parent matters

Anxiety Disorders

• GAD: generalized anxiety disorder• OCD: obsessive compulsive disorder• Phobias• Panic disorders

Scope of Childhood Anxiety

• 25% of 13-18 year olds will experience episodic or chronic anxiety

• 6% of 13-18 year olds will experience severe anxiety

• Female : Male is 60:40

Symptoms of Childhood Anxiety

• Excessive worry• Palpitations, hyperventilation, dizziness• Tremors• Poor concentration• Sleep onset problems• HA, SA, fatigue

Signs of Childhood Anxiety

• Avoidance• Frequent unwarranted tantrums• “CONTROL FREAK!!!”• Hypersensitive and over-reactive

Triggers

• Social challenge like bullying• Academic underachievement• Extracurricular pressure “Overload Syndrome”• Unstable home environment• Moves, new school

Parenting Thought:

• Anxiety leads to high arousal states• Parenting a kid who is in a high arousal state

usually doesn’t work very well• Understand how your child self-protects: rage, withdrawl, power, perfectionism, blame, or self-contempt

Neurobiology 101(These Disorders are Real)

Normal left, OCD right

Doritos left, Nuts right

Serotonin (5-HT)

• Considered our “happy” neurotransmitter

• Regulates mood, appetite, and sleep

• Meds that regulate serotonin used to treat patients with depression, GAD, and phobias

• Receptor Ki (nM)[12] Receptor function[Note 1]

• 5-HT1 receptor family signals via Gi/o inhibition of adenylyl cyclase.

• 5-HT1A

3.17Memory (agonists ↓); learning (agonists ↓); anxiety (agonists ↓); depression (agonists ↓); positive, negative and cognitive symptoms of schizophrenia (partial agonists ↓); analgesia (agonists ↑); aggression (agonists ↓); dopamine release in the prefrontal cortex (agonists ↑); serotonin release and synthesis (agonists ↓)

• 5-HT1B4.32Vasoconstriction (agonists ↑); aggression (agonists ↓); bone mass (↓). Serotonin autoreceptor.

• 5-HT1D5.03Vasoconstriction (agonists ↑)

• 5-HT1E7.53

• 5-HT1F10

• 5-HT2 receptor family signals via Gs activation of phospholipase C.

• 5-HT2A

11.55Psychedelia (agonists ↑); depression (agonists & antagonists ↓); anxiety (antagonists ↓); positive and negative symptoms of schizophrenia (antagonists ↓); norepinephrine release from the locus coeruleus (antagonists ↑); glutamate release in the prefrontal cortex

• 5-HT2B8.71Cardiovascular functioning (agonists increase risk of pulmonary hypertension)

• 5-HT2C

5.02Dopamine release into the mesocorticolimbic pathway (agonists ↓); acetylcholine release in the prefrontal cortex (agonists ↑); appetite (agonists ↓); antipsychotic effects (agonists ↑); antidepressant effects (agonists & antagonists ↑)

• Other 5-HT receptors• 5-HT3 ?Emesis (agonists ↑); anxiolysis (antagonists ↑)

• 5-HT4

125.89Movement of food across the GI tract (agonists ↑); memory & learning (agonists ↑); antidepressant effects (agonists ↑). Signalling via Gαq activation of adenylyl cyclase.

• 5-HT5A251.2Memory consolidation.[13] Signals via Gi/o inhibition of adenylyl cyclase

• 5-HT698.41Cognition (antagonists ↑); antidepressant effects (agonists & antagonists ↑). Gs

signalling via activating adenylyl cyclase.• 5-HT78.11Cognition (antagonists ↑); antidepressant effects (antagonists ↑). Acts by Gs signalling via activating

adenylyl cyclase.

Norepinephrine

• Considered our “focus” neurotransmitter

• Regulates our concentration, attention, mood

• Also our primary “stress” hormone

• Low levels of NE make decisions difficult

Diagnosis and Surveys

• There is no blood test• Brain scan research is still in the early stages• Psychological evaluation through history

taking and surveys usually lead to diagnosis• Depression scales: CDI, PHQ-9• Anxiety scales: SCARED, SCAS, STAIC, RCMAS

Treatment Modalities

• Counseling

• Medications

• CAM-Complimentary/Alternative Medicine

Counseling: CBT

• CBT (Cognitive Behavior Therapy)• Replacement Theory

(recognizing cognitive distortions)• Understanding realistic vs. unrealistic thoughts• “Practical” thinking towards realistic

perspectives• Usually 3-4 months

Counseling: DBT

• DBT (Dialectical Behavior Therapy)• Focuses on self-responsibility for decisions• Gaining self-awareness of conflict and ways to

manage reactions

Counseling: Individual and Family

• Helps individuals understand how anxiety or depression affects relationships

• Teaches ways for individuals and family members to better understand each other

• Works toward healthy communication skills, boundary setting, and cooperation

Medications

• Most commonly used to increase levels of serotonin

• SSRI: Prozac, Zoloft, Celexa, Lexapro, Paxil

• Wellbutrin

Optimal Therapy

• Research has shown a combination of counseling and meds results in the best outcome

• Counseling is usually the best place to begin

• If medications are started, close follow-up is a mandatory expectation

CAM: Complimentary-Alternative Medicine

• Acupressure, acupuncture, biofeedback, chiropractic, dietary supplements, guided-imagery, hypnosis, massage therapy, meditation, relaxation, and yoga

CAM

• Research has been varied as to the efficacy of different alternative therapies

• Many have experienced positive results• Safety of combining traditional medicines with

CAM is not known• Most clinicians believe that using dietary or

herbal supplements should not be done with prescription medications

Research is needed…

• CAM should be evaluated just like traditional methods through double-blinded placebo controlled studies

• Perhaps someday more effective, safer, less expensive, and better tolerated therapies can be found

Parenting Thought: “The Two Things”

• “The Two Things” approach: is the mindset of continuously asking yourself what are two things my child needs to learn next

• It doesn’t matter if your child is on their way to Harvard or on their way to juvenile detention

• It doesn’t matter if they’re four years old or seventeen

“The Two Things”

• Working on “Two Things” at a time is ultimately the most efficient way to grow

• These things might be: doing a good job vacuuming, getting up on

your own, regulating time on video games… or in a countercultural way: being more social,

dressing like a slob now and then, or study less

Final Comments:

• Seek the help you and your family need• Love Must Evolve for your child to grow up• Life Is Difficult is an important life lesson• Avoid parenting in high arousal states• Working on Two Things is the most efficient

way to grow

Break time!!!!!

See you all in 20 minutes…