Depressive Disorders in Children and Adolescents: Identification

and Treatment

Elizabeth McCauley, PHD, ABPP

Professor

University of Washington/Seattle Children’s Hospital

Agenda

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

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

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

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)

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

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

Causal Model?

Stress Diathesis ModelDiathesis—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

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

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)

Why are Adolescents So Vulnerable?

Neurobehavioral Development in Adolescents

Early AdolescencePuberty stimulates changes in brain systems regulating arousal and appetite that

influence intensity of emotion and motivation

Late AdolescenceWith age and experience

comes maturation of frontal lobes which

facilitates regulatory competence

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

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

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

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

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

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

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

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

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

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

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

Case conceptualization Tx Choice

•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

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

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

Duration of Antidepressant Use

0%

20%

40%

60%

80%

100%

Start 1 2 3 4 5 6

Months after initial prescription fill

SSI

Tricyclic

Other

Richardson, DiGiuseppe, Christakis, McCauley, Katon, 2004.

1998

Psychotherapy for Depression: Evidence of Treatment Effects

Reinecke, Ryan & DuBois

6 CBT Trials

ES = 1.02(0.97)

1999 2002 2006

Lewinsohn & Clarke

12 Trials

ES = 1.27

Michael & Crowley

14 Trials

ES = .72

Weisz, McCarty & Valeri

35 TrialsInc. TADS N=439

IPT- 2 trials

ES = .34(0.40 ULS)*

Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149

* Unweighted least squares

2007

The TADS Team, Arch Gen Psychiatry 2007;64:1132-1143.

Adjusted mean Children's Depression Rating Scale-Revised (CDRS-R) total scores

Moving on with Treatment

CBT-the most widely investigated psychotherapy for depression

Aaron T. Beck

“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

Require ability to reflect on, monitor, and evaluate own thinking process in

midst of heightened emotional arousal—may not have skills on board

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

Moving on to Treatment—What Works Best?

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

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.

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

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

Thought Record

What happened? How did you f eel?

What thoughts did you have at the time?

What did you do? Any other way to look at it?

List all the emotions you had at the t ime. Did you f eel some more than others?

What does it mean to you that….? So what? What if ?

Did you want to do something you didn’t do? Do something you wish you hadn’t?

Do you f eel diff erently if you think about it this way? Would you do anything diff erently now?

Supplementary Materials…

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

Middle Sessions:

Cognitive Restructuring:

- Validation

- Downward Arrow

- Evidence Testing

Automatic Thoughts

Underlying Beliefs

Middle Sessions:

Cognitive Restructuring:

- Validation

- Downward Arrow

- Evidence Testing

Using Cognitive Restructuring in Case Conceptualization

Final Sessions:

Relapse Prevention:

‘Becoming Your Own Therapist’

Termination

Core Principles of Interpersonal Psychotherapy

• Link between mood and life events

• Focused, time limited treatment

• “Here and Now” treatment

• Medical Model

• Active Therapist

General IPT techniques

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

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

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?

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

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

Interpersonal Problem Areas

Grief

Interpersonal disputes

Role transitions

Single-parent family situations

Interpersonal deficits

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

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

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”

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

Plug for Treatment Development

Peter Lewinsohn

Behavioral Activation“You can change how you feel by changing what you do”Decrease in frequency or range of reinforcing stimuli or increase in frequency of punishment depression

Allows adolescent to practice with “coach” planning,

monitoring and evaluation skills needed to coordinate affect arousal and cognitive skills w/o direct challenge to

beliefs

Focuses 3 core strategies:• Facilitative• Activation • Processes that inhibit activation:

• Withdrawal• Avoidance• Ruminative thinking

Thanks!