Adolescent Depressive Disorders
Source: NARSAD Newsletter, Fall
2001
by Anne B. Brown
Occurring earlier in life than in past decades, depression in
adolescents is common, recurrent, and associated with significant mortality. Often,
depressive disorders in adolescents go unrecognized by families and physicians
because the symptoms are viewed as normal mood swings typical of a teenage
developmental stage. This can have tragic consequences as mood disorders can
affect the functioning and adjustment of teenagers, leading to an increased
risk for substance abuse and suicidal behavior.
Among adolescents and young adults from 1952 to 1996, a
tripling of suicide rates has occurred---with a 14% increase in suicide among
adolescents aged 15 to 19 years. In 1999, suicide alone accounted for 12% of
all deaths for 10- to 24-year-olds. These disturbing statistics have prompted
the U.S. Surgeon General to recognize suicide as a serious public health
problem and develop a National Strategy for Suicide Prevention.
Suicidal thoughts are surprisingly common in high school
students as reported in the Youth Risk Behavior Surveillance study:
+ 19.3% of 9th- to 12th-grade students in the
+ 8.3% reported at least one suicide attempt
+ 2.6% enacted at least one medically serious suicide attempt
within the year of survey.
Many of the adolescents who attempt or commit suicide have
depressive disorders. Dr. David Shaffer (a 1991 NARSAD Distinguished
Investigator) of
Developing and testing various interventions to prevent suicide
in adolescents has been the focus of many studies. Research has shown that
early diagnosis and treatment, accurate evaluation of suicidal thinking, and
limiting young people’s access to lethal agents (including firearms and
medications) may hold the greatest suicide prevention. As for predicting which
adolescents will actually commit suicide, this has been more difficult to
identify. Dr. Cynthia R. Pfeffer of
+ Pessimism about the future, manifested as hopelessness
+ Poor self-efficacy (helplessness)
+ Poor self-esteem, expressed as worthlessness
+ Recklessness
+ Impulsivity
Adolescent Major Depression
Recognizing depression in teens is more difficult than in adults
because adolescents express their symptoms differently. A youth with depression
is more likely to exhibit decreased interest in formerly pleasurable activities
and irritability rather than low energy, sadness, and increased sleep as is
typically seen in adults.
Emerging treatment studies indicate that adolescents with
depression respond differently from adults. Depressed adolescents do not show
evidence of hypercortisolemia (excessive production
of cortisol) as is frequently reported in adults.
Also, most depressed adolescents fail to respond to tricyclic
antidepressants (TCA). Since there are differences in the mechanism of action
of selective serotonin reuptake inhibitors (SSRIs)
and TCA medications, researchers hope this may provide valuable insights into
the underlying neurobiology of early-onset depression.
Treatment of Depression
Treatment often combines short-term psychotherapy, medication,
and targeted interventions involving the home or school environment. As initial
treatment for mild to moderate depression, psychotherapy teaches adolescents
and their families to cope with inter-personal conflict and the social,
familial, academic, and occupational problems that are associated with
depression. One study found cognitive-behavioral therapy (CBT) to have a 65%
remission rate in adolescents with depression and a more rapid response rate
than either supportive or family therapy. CBT is based on the premise that
depressed patients have cognitive distortions in their views of themselves, the
world and the future. Approximately 15-20 CBT sessions are required, first as
weekly sessions, but as the symptoms abate, monthly. Continuing psychotherapy
is important even after the symptoms have remitted because it can help teens to
better understand how their thoughts and behaviors can contribute to a relapse.
Medication as a first-line course of treatment should be reserved for adolescents
·
with severe symptoms that would prevent effective psychotherapy
unwilling or unable to undergo psychotherapy
·
class
·
who are psychotic
·
who have chronic or recurrent episodes.
Several studies have found selective serotonin reuptake inhibitors
(SSRIs) to be safe and effective for the short-term
treatment of severe and persistent depression in adolescents. Specifically, fluoxetine (Prozac) and paroxetine
(Paxil) have been found to be effective. Except for
lower initial doses, the administration of SSRIs in
adolescents is similar to that for adult patients with a recommended duration
of at least 4 weeks. In the absence of adolescent relapse studies and
considering the adult literature, teens with 2 or 3 episodes of major
depression are recommended to receive maintenance treatment for at least 1 to 3
years. Teenagers with a diagnosis of both depression and anxiety can be acutely
agitated, requiring the prescription of an antianxiety
medication, such as diazepam (Valium) or alprazolam (Xanax), rather than waiting for several weeks for an SSRI
to relieve symptoms.
Adolescent Depressive
Disorders are Common and Potentially Fatal
‚ Major depression affects
approximately 4-8% of adolescents.
‚ Within 5 years of
the onset of major depression, 70% of depressed youths will experience a
recurrence.
‚ Depression in young people
often co-occurs with other mental disorders, most often anxiety, disruptive
behavior, or substance-abuse disorders.
‚ Longitudinal
follow-up studies estimate that 20 to 25% of depressed adolescents will develop
a substance-abuse disorder.
‚ As many as 5 to 10%
of adolescents will complete suicide within 15 years of their initial episode
of major depression.
‚ Although adolescent depression is twice as
common in girls as boys, in post-puberty (ages 15-19),
the male suicide rate is 5 times that of the female rate.
There is a pressing need for additional research on the effectiveness
of psychosocial and pharmacological treatments for depression in youth. Under
the FDA Modernization Act (1997), manufacturers of selected medications already
approved for use in adults, but also prescribed to youths, will need to provide
studies in the pediatric population. Because of these regulations, several
trials of other SSRIs and norepinephrine
serotonin reuptake inhibitors (NSRIs) are ongoing.
Recruitment of subjects for clinical trials and the lack of an adequate
research infrastructure limit the pace of new research in this area. Both industry sponsored and federally funded research has been
hampered by difficulties in recruitment. This is clearly not because of a lack
of children and adolescents with depression but may reflect differences in
access to care, with many patients being treated in primary care or not treated
at all.
Adolescent
Bipolar Disorder
Follow-up studies have found that 20% to 40% of depressed
adolescents develop bipolar disorder within 5 years after the onset of major
depression. These teens are likely to be young at the time of the first
depressive episode, have psychotic features in the initial depression, have a
family history of bipolar disorder, and develop symptoms of hypomania during
treatment with antidepressant drugs. If one parent of an adolescent has bipolar
disorder, the adolescent has a 30% chance of having the disorder, and if both
parents have the disorder, the chance rises to 60%.
This disorder can begin very gradually and be unmasked by an
antidepressant medication, or it can present very suddenly where a teen under
stress becomes manic and agitated, looking almost psychotic. Symptoms of
bipolar disorder can be difficult to distinguish from other problems of
adolescence. For example, while irritability and aggressiveness can indicate
bipolar disorder, they can also be symptoms of depression, conduct disorder,
drug abuse, attention deficit hyperactivity disorder (ADHD), or possibly
schizophrenia. Since about 30% of adolescents with bipolar disorder also have
ADHD, limited evidence suggests that some of the symptoms of ADHD may be a
forerunner of mania.
Depressive Symptoms in Adolescence
+ Vague, non-specific physical complaints such as headaches, muscle
aches, stomachaches or tiredness
+ Absences from school or poor performance in school
+ Talk of or efforts to run away from home
+ Outbursts of shouting, complaining, unexplained irritability, or
crying
+ Being bored
+ Lack of interest in playing with friends
+ Alcohol or substance abuse
+ Social isolation, poor communication
+ Fear of death
+ Extreme sensitivity to rejection or failure
+ Increased irritability, anger, or hostility
+ Reckless behavior
+ Difficulty with relationships
Worsening Outcome?
Some researchers believe that bipolar disorder beginning in
childhood or early adolescence may be a different, possibly more severe form of
the illness than older adolescent- and adult-onset bipolar disorder. When the
illness begins before or soon after puberty, it is often characterized by a
continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur
with disruptive behavior disorders, particularly ADHD or conduct disorder, or
may have features of these disorders as initial symptoms. In contrast, later
adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with
a classic manic episode, and to have a more episodic pattern with relatively
stable periods between episodes.
Dr. Thomas McGlashan of Yale university (a 1997 NARSAD Distinguished/Wodecroft
Foundation Investigator) has studied thirty-five adolescent-onset bipolar
patients for fifteen years. He found that although the adolescent-onset
patients displayed more delusions and hallucinations and were more explosive and
disorganized than the adult-onset patients, the adolescent patients went on to
have an equal or superior outcome to those with the adult-onset form of the
disorder. Dr. McGlashan’s study examined the lives of
a group of people in their mid-forties who became symptomatic in the teenage
years and compared their outcomes to a group of people in their fifties who
became symptomatic as adults. He failed to find significant differences in
their marital status, parental status, living situations, length and number of
hospitalizations, and amount and severity of symptoms. But where differences
did exist---for example, in the frequency of social contacts and amount of work
time in the previous year---the adolescent-onset patients were “consistently
superior.” Dr. McGlashan himself was surprised by the
findings and offered 2 hypotheses.
1. Adolescent-onset mania may be a milder variant that, however,
looks more severe because it emerges during a developmentally vulnerable period
when defenses are in flux and coping strategies are poorly developed. With the
passing of adolescence, however, the disorder becomes less penetrating in its
virulence.
2. Adolescent-onset mania may not be a milder variant but may emerge at
a time when personality structure is flexible enough that the individual can
develop ways of coping more effectively with the illness. Dr. McGlashan speculated that adults who develop the illness
might be more set and rigid, temperamentally less flexible and able to adapt to
the vagaries of the illness.
Manic Symptoms in Adolescence
+ Severe changes in mood---either
extremely irritable or overly silly and elated
+ Overly-inflated self-esteem; grandiosity
+ Increased energy
+ Decreased need for sleep---able to go with very little or no
sleep for days without tiring
+ Increases talking---talks too much, too fast; changes topics too
quickly; cannot be interrupted
+ Distractibility---attention moves constantly from one thing to the
next
+ Hypersexuality---increased sexual
thoughts, feelings, or behaviors; use of explicit sexual language
+ Increased goal-directed activity or physical agitation
+ Disregard of risk---excessive involvement in risky behaviors or
activities
More recently, Dr. Michael Strober,
of the
Treatment for Bipolar Disorder
Treatment of adolescents with bipolar disorder is based mainly
on experience with adults, because limited data exist on the safety and
efficacy of mood stabilizing medications in youth. Treatment usually involves
an appropriate dose of mood stabilizing medications, typically lithium and/or valproate (Depakote), which are
often very effective for controlling mania and preventing recurrences of manic
and depressive episodes. Using antidepressant medication to treat depression in
a person who has bipolar disorder may induce manic symptoms if it is taken
without a mood stabilizer. In addition, using psychostimulant
medications to treat ADHD or ADHD-like symptoms in an adolescent with bipolar
disorder may worsen manic symptoms.
Caution needs to be applied in treating young female patients
with valproate. According to studies conducted in
Few studies have been conducted with alternative treatments for
adolescents with bipolar disorder, such as neuroleptics;
however, a few small open studies and retrospective chart reviews have been
conducted. One study reported on 18 adolescents (aged 13 to 18) who were
treated with gabapentin following a failure of a mood
stabilizer. Eighty-nine percent described a cessation of cycling, whereas 33%
felt improved mood. In a retrospective chart review, another study reported on
28 bipolar children and adolescents, aged 4 to 17, who were treated with risperidone for an average of 6 months, 82% felt improved
mania and aggression and 69% showed improved psychosis.
For more information, contact:
The
NAMI of Greater
(312)
563-0445