Depression OverviewDepression Overview

Developed by the Center for School Mental Health with support Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the National provided in part from grant 1R01MH71015-01A1 from the National

Institute of Mental Health and Project # U45 MC00174 from the Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Office of Adolescent Health, Maternal, and Child Health Bureau,

Health Resources and Services Administration, Department of Health Resources and Services Administration, Department of Health and Human ServicesHealth and Human Services

Depressive DisordersDepressive Disorders

Major Depressive Disorder

Dysthymic Disorder

Depressive Disorder Not Otherwise Specified (NOS)

DepressionDepressionEpidemiology

2.5% of children, up to 5% of adolescents Prepubertal-1:1/F:M; adolescence-4:1/F:M Average length of untreated Major Depressive

Disorder – 7.2 months Recurrence rates-40% within 2 years

Heredity

Most important risk factor for the development of depressive illness is having at least one affectively ill parent

DepressionDepressionModifications in DSM- IV for children:

irritable mood (vs. depressive mood) observed apathy and pervasive boredom (vs. anhedonia) failure to make expected weight gains (rather than

significant weight loss) somatic complaints social withdrawal declining school performance

What type of depression??What type of depression?? Tonya has come for an initial appointment to the

SBHC. During the risk assessment, Tonya reports a number of depressive symptoms, including suicidal ideation. Tonya seems to display a lot of negative thinking and cognitive distortions. For example, she believes that “nobody” likes her and that she will “never” be successful in school. Her math teacher often compliments her work, but Tonya dismisses the teacher’s comments as him “just trying to be nice.” Tonya has good grades in all classes except for one, yet she only acknowledges her below average Chemistry grade. Tonya has felt extremely sad for about three weeks, which is a contrast from her usually happy disposition.

Major Depressive DisorderMajor Depressive Disorder Major Depressive Episode:

Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning. At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure.

– Depressed mood most of the day, nearly every day, as indicated by subjective report or based on the observations of others. In children and adolescents, this is often presented as irritability.

– Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

– Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day

– Insomnia or hypersomnia nearly every day– Psychomotor agitation or retardation nearly every day (observable by others)– Fatigue or loss of energy nearly every day– Feelings of worthlessness or inappropriate guilt nearly every day– Diminished ability to think, concentrate, make a decision nearly every day– Recurrent thoughts of death, recurrent suicidal ideation with or without a specific

plan, or an actual suicide attempt

Major Depressive DisorderMajor Depressive Disorder

II. Symptoms cause clinically significant distress or impairment in social or academic functioning

III. Symptoms are not due to the direct physiological effects of a substance (drugs or medication) or a general medical condition

Although there is a different diagnostic category for individuals who suffer from Bereavement, many of the symptoms are the same and counseling techniques may overlap.

What type of depression??What type of depression??Maria comes for a follow-up appointment

to the SBHC. Her risk assessment showed that she has felt sad or blue for at least two weeks. Upon further inquiry, Maria reports that she generally feels sad, and finds little enjoyment in activities. She reports having felt this way for several years. In fact, she can’t recall a time when she didn’t feel mostly down. She denies suicidal ideation, and is doing pretty well in school. She is not very social, but does have a few friends.

Dysthymic DisorderDysthymic Disorder Major difference between a diagnosis of Major

Depressive Disorder and Dysthymia is the intensity of the feelings of depression and the duration of symptoms.

Dysthymia is an overarching feeling of depression most of the day, more days than not, that does not meet criteria for a Major Depressive Episode.

Impairs functioning and lasts for at least one year in children and adolescents, two in adults.

Depressive Disorder NOSDepressive Disorder NOS

Disorders with depressive symptoms BUT do not meet criteria for: Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood

Examples: premenstrual dysphoric disorder, minor depressive disorder (at least 2 weeks, but < 5 symptoms)

Also used in situations in which clinician has concluded that a depressive disorder is present, but is unable to determine whether it is primary, due to medical condition, or substance induced

Depression Versus Normal Adolescent Development

Adolescent DevelopmentAdolescent Development

Adolescent DevelopmentAdolescent Development

Periods of transient milder problems with low self-esteem, anxiety, depressive feelings are quite common.

Needs to be differentiated from clinical depression!

Depression and Suicide

SuicideSuicide

Attempts- 3:1/F:M, Completions- 4:1/M:F

Most common means of completed suicide: FIREARMS

Most often associated with depressive disorder.

Risk factors: Age, sex, presence of psychiatric illness, family history, isolation from friends, substance abuse

Adolescents and SuicideAdolescents and Suicide In 1998, 4,153 young people, ages

15-24, committed suicide in the United States an average of 11.3 per day.1

Suicide is the third leading cause of death in this age group following unintentional injury and homicide2

Suicide accounts for 13.5% of all deaths in this age-group1

1 Murphy, SL, 1998 2 The Surgeon General’s Call to Action to Prevent Suicide, 1999

Mortality in ChildrenMortality in Children Ages 1-19 yearsAges 1-19 years

SuicideHomicideAccidentsCancerCongenitalOther

Source: CDC Wonder Mortality Statistics; Center for Disease Control and Prevention, 2001

MH interventions shown to be MH interventions shown to be EFFECTIVE for depressive or EFFECTIVE for depressive or withdrawn behavior problemswithdrawn behavior problems

“Of the available services reviewed, Cognitive Behavioral Therapy remains the intervention of choice… Interpersonal Therapy appears to be a reasonable alternative to CBT”

What is Cognitive Behavior Therapy (CBT)?What is Cognitive Behavior Therapy (CBT)?Relatively short-term, focused

psychotherapy

Focus:– How you are thinking (your cognitions)– How you are behaving and communicating

Emphasis on present rather than past

Learn coping skills

What is Interpersonal Therapy (IPT)?What is Interpersonal Therapy (IPT)?

Short term, usually involves up to 20 sessions

Focuses on 1-2 key interpersonal issues most closely related to the depression.

Interpersonal events include:– interpersonal disputes / conflicts

– interpersonal role transitions

– complicated grief

MH interventions with little or NO MH interventions with little or NO evidence of effectiveness for Depression:evidence of effectiveness for Depression:

Family Therapy*RelaxationSelf-Control TrainingSelf-ModelingNon-directive Supportive Therapy

* note: Family Engagement in CBT and IPT, however, has been shown to be important!

Practice Elements for DepressionPractice Elements for Depression

Child Psychoeducation Cognitive/Coping Problem Solving Activity Scheduling Skill-building/Behavioral

Rehearsal Social Skills Training Communication Skills Parent Psychoeducation