2. Adolescent DepressionAdolescent Depression
Prof. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
Chairman of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA member

3. Agenda
• Introduction & History
• Scope of the problem
• Etiology
• Clinical Manifestation
• Suicide
• Management

4. Teen Depression

5. Question
Depression is a choice.
True or False

6. What is Depression?
-Depression is a medical illness
-Major depressive disorder is
(reoccurring periods of depression)
-It is not just the feeling of “ups” and “downs:
It is the most common mood disorder
Major depressive disorder is classified by the feeling of sadness
and loss of interest in nearly all activities for at least 2 weeks

7. Severity of Problem ….
Untreated Depression can be taken as important cause
of suicide in adolescentssuicide in adolescents, even adults

8. A Brief History of Depression in Children andA Brief History of Depression in Children and
AdolescentsAdolescents
• Case reports on childhood depression date to theCase reports on childhood depression date to the early 17early 17thth
centurycentury
• Melancholia in children was first reported in theMelancholia in children was first reported in the mid-19mid-19thth
centurycentury
• In general, however, the existence of depression prior toIn general, however, the existence of depression prior to
1960 was seriously doubted because it was felt that1960 was seriously doubted because it was felt that
childrenchildren’s’s immature superegoimmature superego would not permit thewould not permit the
development of depressiondevelopment of depression
• Research from Europe and NIMH funded American studiesResearch from Europe and NIMH funded American studies
in the 1970in the 1970’s increased the awareness & acceptance of’s increased the awareness & acceptance of
childhood depressionchildhood depression

9. 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)

10. 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

11. 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

12. Complexities in Diagnosing MDD in Children and
Adolescents
• Overlap of mood disorder symptoms
• Symptoms overlap with comorbid disorders
• Developmental variations in symptom manifestations
• Etiological variations of mood disorders involving gene-
environment interactions
• Are disorders spectrum or categorical disorders
• Effects of medical conditions

13. Need to Recognize Developmental Variations of
MDD
CHILDREN:
• More symptoms of anxiety (i.e.
phobias, separation anxiety),
somatic complaints, auditory
hallucinations
• Express irritability with temper
tantrums & behavior problems,
have fewer delusions and
serious suicide attempts
ADOLESCENTS:
• More sleep and appetite
disturbances, delusions,
suicidal ideation & acts,
impairment of functioning
• Compared to adults, more
behavioral problems

14. Differential Diagnosis: Complexities of Diagnosing
MDD
• Overlap of symptoms with nonaffective disorders (i.e.,
anxiety, learning, disruptive, personality, eating
disorders):
• Overlapping symptoms include: poor self-esteem,
demoralization, poor concentration, irritability, dysphoria,
poor sleep, appetite problems, suicidal thoughts, being
overwhelmed

15. Seeking Help
Many people feel ashamed or afraid to seek help,
others make light of their symptoms leading
them to suffer in silence.
It’s important to remember that depression isn’t a
character defect or something that you have
brought on yourself

16. Understanding Psychiatric Disorders
Genetics
Prenatal environment
Attachment
Temperament
Parenting
Exposures
Phenotype
SES
Comprehensive
Treatment

17. Causes of Depression in TeensCauses of Depression in Teens
 StressStress
 LossLoss
 Major disappointmentMajor disappointment
 Chemical imbalanceChemical imbalance
 Genetic dispositionGenetic disposition
 Some medications (i.e. narcotics, steroids) may triggerSome medications (i.e. narcotics, steroids) may trigger
depressiondepression
 Traumatic events (violence, abuse, neglect)Traumatic events (violence, abuse, neglect)
 Social problemsSocial problems
 Unresolved family conflictUnresolved family conflict
http://www.bchealthguide.org/kbase/topic/major/ty4640/course.htm

18. Why are Adolescents So Vulnerable?

19. Neurobehavioral Development in
Adolescents
Early Adolescence
Puberty stimulates
changes in brain systems
regulating arousal and
appetite that influence
intensity of emotion and
motivation
Late Adolescence
With 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

20. Stress in students leading to depression
• Parental pressure to perform and to stand out among
other children
• If not come up to expectations
• Frustration
• Physical stress
• Aggression
• Undesirable complexes

21. • Extreme sensitivity to rejection or failure
• Low self-esteem and feelings of guilt
• Frequent complaints of physical illnesses such as
headaches and stomachaches
• Frequent absences from school or poor performance in
school
• Threats or attempts to run away from home
• Major changes in eating or sleeping patterns
(American Academy of Child and Adolescent Psychiatry, 8/98)
Symptoms of Major Depression:Symptoms of Major Depression:
Adolescents with depression may display some of the following signsAdolescents with depression may display some of the following signs

22. • Sad, blue, irritable and/or complains that nothing is fun
anymore
• Trouble sleeping, low energy, poor appetite and trouble
concentrating
• Socially withdrawn or performs more poorly in school
• Can be suicidal
National Institute of Mental Health, Treatment of Adolescent Depression Study (TADS)
Symptoms of Major Depression:Symptoms of Major Depression:
Adolescents with depression may display some of the following signsAdolescents with depression may display some of the following signs

23. Adolescent Anxiety
• Excessive worries
• Worries about school performance
• Difficulty making friends
• Isolative
• Perfectionistic
• Rigid thinking and behavior patterns
• Phobias

24. ConsiderConsider…..…..
 It was once thought that only adults developed depression and that
children and teens could not.
 Symptoms of depression in children and teens can be difficult to
recognize.
 Mood swings and other emotional changes caused by depression
may be overlooked as unimportant or as a normal part of growing up.
 Prolonged or severe depression can lead to problems making and
keeping friends, difficulty in school, substance abuse, suicidal
behaviour, and other problems that may carry into adulthood.
Government of British Columbia- B.C. Health Guide: Depression in Childhood and Adolescence
http://www.bchealthguide.org/kbase/topic/major/ty4640/course.htm

25. Depression thinking can become part of a child’s developing personality,
leaving long-term effects in place for the rest of the child’s life.
Future of depressed school-age children….
• School performance and learning
• Lack of trust – can lead to Substance abuse
• Disruptive behaviour
• Violence and Aggression
• Legal troubles and even suicide

26. Clinical Course: Relapse
• Relapse is an episode of MDD
during period of remission
• Predictors of relapse: Natural
course of MDD, Lack of
compliance, Negative life
events, Rapid decrease or
discontinuation of therapy
• 40%-60% youth with MDD
have relapse after successful
acute therapy
• Indicates need for continuous
treatment

27. Clinical Course: Recurrence
• Recurrence is emergence of
MDD symptoms during period
of recovery (asymptomatic
period of more than 2 months)
• Clinical & nonclinical samples
probability of recurrence 20%-
60% in 1-2 years after
remission, 70% after 5 years
Recurrence predictors:
• Earlier age at onset
• Increased number of prior
episodes
• Severity of initial episode
• Psychosis
• Psychosocial stressors
• Dysthymia & other comorbidity
• Lack of compliance with
therapy

28. Clinical Course: Risk of Bipolar Disorder
• 20%-40% MDD youth develop bipolar disorder in 5 years of onset of
MDD
• Predictors of Bipolar I Disorder Onset:
• Early onset MDD
• Psychomotor retardation
• Psychosis
• Family history of psychotic depression
• Heavy familial loading for mood disorders
• Pharmacologically induced hypomania

29. Suicidal Ideation among Adolescents
(Hoberman and Garfinkel 1988)
In a study of 229 completed youth suicides:
• 62% had made a suicidal statement
• 45% had consumed alcohol within 12 hours of killing
themselves
• 76% had shown a decline in academic performance in the
past year

30. Teen Suicide in the U.S.
• There are 25 suicide attempts for every
completion for our country as a whole
• There are between 100-200 teen attempts before
completing suicide
• Girls attempt more often (3:1)
• Boys complete suicide more often (4:1)
• Every year approximately 2,000 teens suicide
Journal of American Academy of Child and Adolescent Psychiatry, Practice Parameters,
2002

31. Although suicide is the 11th
leading cause of death for the overall
population, it is the 3rd
leading cause of death for 15-24 year olds.

32. Risk Factors for SuicideRisk Factors for Suicide
 Current suicidal thoughts
 Other mental health or disruptive disorders, such as conduct
disorder
 Impulsive or aggressive behaviours
 Feelings of hopelessness
 A history of past suicide attempts
 A family history of suicidal behaviour or mood disorders
 A history of being exposed to family violence or abuse
 Access to firearms or other potentially lethal means
 Social isolation/alienation
Government of British Columbia- B.C. Health Guide: Depression in Childhood and Adolescence
http://www.bchealthguide.org/kbase/topic/major/ty4640/course.htm

33. Some common precipitants of suicidal
behavior in teenagers include:
 death of a family member or close friend (particularly if by suicide)
 loss of a romantic relationship or good friendship
 loss of a parent through divorce or separation
 loss of a pet, treasured object, job or opportunity
 fear of punishment
 physical, sexual or psychological abuse
 unwanted pregnancy
 poor grades
 fight or argument with family member or loved one
 belief one has harmed or brought harm to a family member or friend
 embarrassment or humiliation
 concerns about sexuality
 suicide of a friend

34. Treatment of MDD in Children & Adolescents
• Psychotherapy for mild to moderate MDD
• Empirical effective psychotherapies: CBT, ITP
• Antidepressants can be used for: non-rapid cycling
bipolar disorder, psychotic depression, depression with
severe symptoms that prevents effective psychotherapy
or that fails to respond to adequate psychotherapy
• Due to psychosocial context, pharmacotherapy alone
may not be effective

35. Treatment of MDD in Children & Adolescents
• Few studies of acute treatment with medication for
MDD
• Few pharmacokinetic & dose-range studies
• SSRI’s may induce mania, hypomania, behavioral
activation (impulsive, agitated)
• No long-term studies of treatment of MDD; long-term
effects of SSRI’s not known

36. Treatment of MDD in Children and Adolescents
• Small number of case reports (King et al, 1991; Teicher et al., 1990)
described association between SSRI’s treatment and increased
suicidal tendencies, possibly linked to behavioral activation or
akathisia
• Abrupt discontinuation with SSRI’s with shorter half-lives may induce
withdrawal symptoms that mimic MDD
• SSRI’s inhibit metabolism of some medications metabolized by
hepatic enzymes (P450 isoenzymes)
• SSRI’s interact with other serotonergic medications (MAOI’s) to
induce serotonergic syndrome (agitation, confusion, hyperthermia)

37. How is Teenage Depression Treated?
Depression is commonly treated
with therapy or with therapy and
medication. A combination of
approaches is usually most
effective:
 Cognitive-behavioral therapy focuses on the
causes of the depression and helps change negative
thought patterns.
 Group therapy is often very helpful for teens,
because it breaks down the feelings of isolation that
many adolescents experience (sometimes it helps
just to know that "I'm not the only one who feels this
way").
 Family therapy as an adjunct to individual therapy
can address patterns of communication and ways
the family can restructure itself to support each
member, and can help the teenager feel like others
share the responsibility for what happens in the
family.
Physical exercisePhysical exercise is helpful in lifting depression, as itis helpful in lifting depression, as it
causes the brain's chemistry to create morecauses the brain's chemistry to create more
endorphins and serotonin, which change mood.endorphins and serotonin, which change mood.
Creative expressionCreative expression through drama, art or music is oftenthrough drama, art or music is often
a positive outlet for the strong emotions ofa positive outlet for the strong emotions of
adolescents.adolescents.
Volunteer workVolunteer work is sometimes helpful for adolescents.is sometimes helpful for adolescents.
Helping someone else whose problems are greaterHelping someone else whose problems are greater
than one's own offers a perspective and also anthan one's own offers a perspective and also an
opportunity to be helpful, which can increase one'sopportunity to be helpful, which can increase one's
sense of purpose and meaning.sense of purpose and meaning.
MedicationMedication for depression should be used with greatfor depression should be used with great
caution, and only under careful supervision. Recentcaution, and only under careful supervision. Recent
studies by both the UK government and the FDA havestudies by both the UK government and the FDA have
led to warnings that not all psychiatric drugs may beled to warnings that not all psychiatric drugs may be
appropriate for teenagers and children. Seek aappropriate for teenagers and children. Seek a
physician who works specifically with teenagers.physician who works specifically with teenagers.
HospitalizationHospitalization may be necessary in situations where amay be necessary in situations where a
teen needs constant observation and care to preventteen needs constant observation and care to prevent
self-destructive behavior. Hospital adolescentself-destructive behavior. Hospital adolescent
treatment programs usually include individual, grouptreatment programs usually include individual, group
and family counseling as well as medications.and family counseling as well as medications.
Helpguide.org: “Teen Depression”
http://www.helpguide.org/mental/depression_teen.htm#symptoms

38. Take SUICIDE Seriously
Even if they are only thoughts about suicide take them
seriously!
The risk of suicide increases in those with depression and it's
important to take suicidal thoughts seriously.

39. What parents can
do for their teen:
 Respond with love, kindness, and support
 Repeatedly let your child know that you are there, whenever she
or he needs you
 Be gentle but persistent if your adolescent shuts you out
 Do not criticize or pass judgment once the adolescent begins to
talk
 Encourage activity and praise efforts to socialize and be active
 Seek help from a doctor or mental health professional if the
adolescent's depressed feeling doesn't pass with time
Helpguide.org; “Teen Depression
http://www.helpguide.org/mental/depression_teen.htm#symptoms

40. Antidepressant SalesAntidepressant Sales
• Prescriptions for antidepressants have dropped by 20% for those 18Prescriptions for antidepressants have dropped by 20% for those 18
y/o and younger since 2004 when FDA initial warnings werey/o and younger since 2004 when FDA initial warnings were
publishedpublished
• Sales of antidepressants among adults were down 14% in 2005Sales of antidepressants among adults were down 14% in 2005
• Sales are climbing again in 2006Sales are climbing again in 2006

41. • Depression in children and adolescents is a serious
problem with potentially disastrous outcomes
• Practical and effective approaches to assessment and
treatment have now been organized
• Several well supported treatment options exist both
pharmacologically and nonpharmacologically
• Antidepressants should be respected, but not feared
Take Home Message