Depression in adolescents is a serious issue. Major Depressive Disorder is diagnosed when a depressed mood or loss of interest persists for at least two weeks and causes functional impairment. Adolescence is a period of heightened vulnerability due to brain development and sensitivity to social and environmental factors. Risk factors for adolescent depression include bullying, media use, sleep problems, family history, stressful life events, and LGBTQ identity. Left untreated, depression can have long-term negative consequences including poor outcomes, recurrence of depression, and increased suicide risk. Current treatment approaches include psychotherapy such as CBT and medication like SSRIs, though medications may have side effects in teens. Future directions focus on mindfulness, acceptance, and improving emotion regulation skills. Maint
2. What we are discussing today
Little “d” depression
‒ “That movie made me so depressed”;
‒ “I’m so depressed, they ran out of my favorite potato chips”
vs.
Major Depressive Disorder (MDD)
‒ At least 2 weeks of depressed mood or losing interest in
pleasurable activities
‒ Functional impairment in social, occupational, or educational
settings
11/16/2015Adolescent Depression: Who is at risk and why?2
3. The Burden of Depression: DALYs
11/23/2015Adolescent Depression: Who is at risk and why?3
Disability-Adjusted Life Years
(DALYs): years lost to early
death, disability, or poor health
caused by the illness1
1World Health Organization (2012)
http://www.who.int/healthinfo/global_burden
_disease/estimates/en/index2.html; Whiteford
et al., 2010, Lancet
Worldwide, mental health
disorders account for 7.4% of
disease burden2
4. DALYs for mental health disorders by age1
Adolescent Depression: Who is at risk and why?4
1Whiteford et al. 2010. The Lancet
11/16/2015
5. Adolescent Depression in the U.S.
11/23/2015Adolescent Depression: Who is at risk and why?5
National Survey on Drug Use and
Health, Mental Health Findings;
SAMHSA 2013
7. Adolescence as a sensitive period of development
A developmental period marked by greater sensitivity to stimuli
Adolescence is a sensitive period for the development of the social brain1,2
• Heightened sensitivity to social cues
• Heightened influence peers
• Important rewards and threats are in the social domain; high sensitivity to
social rejection
Adolescence is a time of great learning, adaptation, and motivation
But also a time of vulnerability
Presentation Title and/or Sub Brand Name Here7
1Dahl et al., 2012, Nature Neuro Rev; 2Blakemore, 2014, Annu Rev
Psychol
11/16/2015
8. Bullying
20% report being bullied at school1
Much higher rates among LGBTQ youth2
risk for depression/suicidal ideation3
Cyber bullying
• 20-40% of kids are victims4
• Females and sexual minority youth at
greater risk4
• risk for suicidality4
Adolescent Depression: Who is at risk and why?8
1CDC, 2014, MMWR Surveillance Summaries; 2CDC, 2009, YRBS Results;
3Klomek et al., 2007, JAACAP; 4Aboujaoude et al., 2015, J Ad Health
11/16/2015
9. Media Use Among Teens
TV exposure may increase
depressive symptoms1
High screen time:
• exposure to unattainable body
images, violence, normalization
of drug/alcohol use2,3
• attention, obesity, school
problems
AAP: <2 hours per day; screen free
zones
Adolescent Depression: Who is at risk and why?9
Kaiser Study on Media Use (Rideout et al., 2010)
1Primack et al, 2009, JAMA; 2Stice, 2001, JSCP; 3Brown et al, 2002, J
Ad Health
11/16/2015
10. Sleep
Media use associated with later bed
times and shorter sleep duration1
Teens need more sleep than
adults2
25% report <6hrs of sleep3
Many hormones released during
puberty affected by sleep4
Disrupted sleep is often a symptom
but may also be a cause of
depression in teens4,5
Earlier bedtimes may reduce risk of
depression6
Adolescent Depression: Who is at risk and why?10
1Cain, 2010, Sleep Medicine; 2Carskadon, 2004, Ann N Y Acad Sci;;
3Wolfson, 1998, Child Dev.; 4Dahl et al, 2002, J Ad Health; 5Roberts, 2009,
J Adol.; 6Gangwisch et al.2010, Sleep.
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11. Who else is at risk for developing depression?
Teens with parents or siblings with depression1
Teens exposed to violence and abuse1
Teens experiencing stressful life events (divorce, death of a loved one) 1
LGBT youth2
Drug and alcohol users3
Teens with other physical or mental health problems1
Adolescent Depression: Who is at risk and why?11
1Birmaher et al., 1996, JAACAP; 2Marshall et al, 2011, JAH; 3Halfors, 2005, Am
J Prev Med
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12. Depressed adolescents have a higher risk for…
Poor school outcomes1
Future, more severe depression1
Poor relationships1
Drug and alcohol use 1
Suicide
• 3rd leading cause of death2
• Suicide attempts: 2x higher in female
teens in past year2
• Suicide: 4x higher in males; 77.9%2
• MDD most significant risk factor3
Adolescent Depression: Who is at risk and why?12
1Birmaher et al., 1996, JAACAP; 2CDC, 2015; 3Brent, 1993, JAACAP
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13. Take Home Points
Rates of depression increase dramatically during adolescence
Girls are at greater risk than boys
Adolescence is a sensitive period of development with many social, physical,
and psychological changes the Social Brain
Bullying, media use, and sleep patterns have important implications for
adolescent depression
Some teens are at greater risk for depression because of their family history
and life experiences
Adolescent depression has many negative effects on future outcomes
Adolescent Depression: Who is at risk and why?13 11/16/2015
14. What Does Depression
Look Like in the Brain?
11/23/2015
Olga Tymofiyeva, PhD
Department of Radiology and Biomedical Imaging
15. “It is all in your head”
11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD1
17. 11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD3
k-spaceRadio-
Frequency
Pulses
Gradient
pulses
Received
signal
Magnetic resonance imaging
MRI image
24. Take Home Points
11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD10
• MRI is a safe and sensitive method for studying the brain
• The brain does not fully mature till about 25 years old
• Brain of depressed adolescents (e.g. reward circuit) looks different
• Both, genes and environment shape the brain and may increase risk
for depression
• Adolescence is also a window of opportunity: the brain is plastic,
adaptive and changes with environment
25. Adolescent Depression
Diagnostics, current treatment strategies and future directions
11/16/15
Eva Henje Blom M.D., Ph.D.
Department of Psychiatry and the Osher Center for Integrative Medicine
28. The DSM system is used for diagnoses of mental
disorders
and based on symptom criteria
Eva Henje Blom28
The DSM system does not take into consideration that
depression symptoms change across the life span and differ between genders
29. ADULTS TEENAGE GIRLS TEENAGE BOYS
Mood Sad, depressed Sad, depressed or irritable
Activity Inhibition Agitation
Sleep Early morning wake up Insomnia, delayed sleep phase
Appetite, weight Decreased appetite – weight loss Increased appetite - weight gain
Impulsivity Non impulsive behavior Impulsive behavior internalized:
self-harming, binge eating
Impulsive behaviour externalized:
behavioral problems, risk-taking,
substance abuse
Symptom criteria of Major Depressive Disorder (MDD)
29 Eva Henje Blom
Required symptoms
Depressed, sad or irritable mood and/ or a loss of interest or pleasure in daily activities
Present for most of the time for more than two weeks
Impaired function in daily life
32. Eva Henje Blom32
Deal with a crisis here and now
Manage life
Create a sense of safety and hope
An alliance that can be trusted
Help regulate emotions and sleep
Make sense for the adolescent, transparent
In the acute situation
33. Cognitive Behavioral Therapy (CBT)
Eva Henje Blom33
By identifying and challenging negative thinking such as rumination and worrying
the world may be perceived and interpreted in more functional ways
Top-down cognitive control of emotional processes
Interpersonal Psychotherapy (IPP)
Dialectic Behavioral Therapy (DBT)
Focuses on increasing social support and
managing relationships that contribute to and maintain emotional stress
Learning behavior of both acceptance and change
Acceptance skills = being mindful and increase tolerance to distress
Change-oriented skills = emotion regulation and interpersonal skills
Evidence-based psychological treatments
34. Antidepressant drugs
Eva Henje Blom34
Selective Serotonin Reuptake Inhibitors (SSRIs)
are the most commonly used antidepressants for
teenagers
14.2% of US teenagers with mood disorders are being
prescribed SSRIs Ref: Merikangas et al. Medication use in US youth with
mental disorders. JAMA pediatrics. 2013
Fluoxetine (Prozac) is the only SSRI approved for
teenagers
For teatment resistant depression other drugs are also
being used
Less effective in teenagers compared to adults
It has not been proven that
depression is caused by deficiency
of any specific neurotransmitter
35. Side effects of SSRIs in adolescents
Eva Henje Blom35
Very common:
sleep disturbances
diarrhea, nausea
headache
tiredness
Common:
sexual dysfunction
changes in appetite and weight
anxiety, restlessness
concentration difficulties
Specific to adolescents:
increased aggressive and violent behavior
increased suicidal ideation:
serious warning issued by FDA up through age 24
Important:
emotional blunting and indifference
symptomatic worsening during the first weeks of treatment
withdrawal symptoms at discontinuation
37. Behavioral Activation (BA)
11/23/2015Eva Henje Blom37
Targets behaviors that might maintain or worsen the depression
to create positive change
Helps people understand environmental sources of their depression
38. Shift away from rumination and worrying
by practicing present-moment sensory and interoceptive awareness
Help recognizing emotions in the body and improve attention
Eva Henje Blom38
Mindfulness-based skills
Mindfulness techniques are also applied in school based preventions
such as Socio Emotional Learning (SEL)
39. Find out what you value the most in your life
Challenge patterns of emotional avoidance
Eva Henje Blom39
Acceptance Commitment Therapy (ACT)
40. Training for Awareness Resilience and Action
TARA
TARA is developed at UCSF and based on
current neuro-scientific findings of adolescent
depression and brain development
Targets primarily amygdala hyper-reactivity and improve
emotion regulation and attention skills through bodily practices
such as breathing and slow movement
TARA is currently being tested with behavioral and
neuroimaging outcomes as part of the BrainChange Study
11/23/2015Eva Henje Blom40
41. Connection & Trust
Eva Henje Blom41
Cultural humility
Empathic listening
Authenticity
Seek support
Give the rationale
Maintain connection
even when being dismissed
Editor's Notes
This graph shows the 12-mo prevalence of major depressive disorder among adolescents only. Defined as a period within the last year of two weeks or longer during which the respondant had a depressed mood or loss of interest or pleasure, and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, and self-image.
Couple of points to take away from this graph:
10.7% (or 1 out of 10) adolescence experienced a depressive episode in a 12 month period- this represents 2.6 million adolescents; important to note that this is actually higher than the 12months prevlance for adults which is 6.7%
Much higher prevalence in girls than boys (about 3 times higher) (Dr. Hinshaw will talk more specifically about this difference and why it might be)
Increase in prevalence across the adolescent transition
Differences in prevalence rates by race/ethnicity
So we’ve seen that rates of depression really seem to increase during adolescence, so let’s talk a little bit about….
Dr. Hinshaw will talk more specifically about why we might see this higher rate of depression among adoelscent girls, but first I want to talk a bit about why adoelscent depression is important to address
Lifetime prevalence of depression among adults is still higher in adults (16%) with 11% among adolescence. ; Dr. Hinshaw will address this.
The 12-month prevalence data for major depressive episode presented here are from the National Survey on Drug Use and Health (NSDUH). Based mainly on the 4th edition of theDiagnostic and Statistical Manual of Mental Disorders(DSM-IV), in the NSDUH study a major depressive episode is defined as: Unlike the definition in the DSM-IV, no exclusions were made for a major depressive episode caused by medical illness, bereavement, or substance use disorders.
In 2013, an estimated 2.6 million adolescents aged 12 to 17 in the U.S. had at least one major depressive episode in the past year. This represented 10.7 percent of the U.S. population aged 12 to 17.
Photo credit: EPFL, Human Brain Project
GAD and SAD are highly co-morbid with MDD in teenagers.
Even if they don´t meet full criteria the can have sub threshold symptoms, dysthymia