Depression and anxiety disorders are common psychiatric disorders during adolescence. According to the World Health Organization, these disorders contribute the largest single burden of disease in young people (World Health Organization, 2003). Depression and anxiety disorders may occur concurrently or separately. Individually, each disorder is often accompanied by symptoms of the other and both are often preceded by impairing anxiety symptoms that start in childhood. Childhood anxiety is in fact one of the best predictors of depression later in life. Early diagnosis and effective interventions can enhance the short- and long-term functioning and prevent or significantly modify the characteristic lifelong chronic nature of these illnesses.
Depression, as a clinical entity, is the prolonged presence of persistent low mood, negative cognition, and withdrawn behavior that leads to significant functional difficulties in many aspects of life (social, interpersonal, family, educational, and vocational). It must be differentiated from the usual, expected, and relatively transient mood difficulties that most individuals experience in the course of their daily living, which in popular parlance is also called depression, as well as from a state of “demoralization,” which is a more prolonged mood disturbance, usually resulting from ongoing negative life experiences. The importance of differentiating “normal” transient low mood states and demoralization phenomenon from clinical depression in adolescents may be difficult. Mood states during the teen years may fluctuate rapidly and may be expressed in a variety of different affective, cognitive, and behavioral dimensions, some of which, if not critically considered, may be mistaken for symptoms of a clinical depression. For example, the teen who emphatically states, “I am so depressed that I can not stand it”; or the teen who thinks “now that my boyfriend has left me I can't go on with life”; or the teen who locks himself in his room for a couple of days because he was removed from the basketball team, may not be depressed at all, but just be demonstrating the expected enhanced emotionality of the adolescent years. Careful diagnostic assessment is necessary to avoid overdiagnosis and subsequent exposure to unnecessary treatment or underdiagnosis and subsequent denial of needed treatment. In the clinical situation, it may take two or more visits and an independent perspective (such as that of the parents) before the clinician is able to determine the presence or absence of a depressive syndrome with a high degree of certainty (Table 78.1).
These data illustrate the importance of differentiating depressive symptoms from clinical depression (Kessler et al., 2001; Birmaher et al., 1996a,b).
Trends in suicide rates across the lifespan tend to parallel those of depression with low suicide rates reported prepubertally followed by a rapid rise in suicide rates over the adolescent years, peaking in early adulthood and remaining relatively level until the geriatric phase of the life cycle. In the United States, adolescent suicide is consistently amongst the top three causes of mortality in this age-group. It is highly correlated with unidentified
and untreated depression. Although suicide rates in adolescents have increased over the period 1950 to 1990, the last decade has seen a significant decrease in suicide rates in the United States. Although the reasons for this are not clear and the cause is likely to be multifactorial, there is a strong association between this decrease in suicide and an increase in the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of adolescent depression (Simon et al., 2006; Olfson et al., 2003; American Academy of Pediatrics, Committee on Adolescence, 2000). See Tables 79.3 and 79.4 for suicide rates in high school students from the Youth Risk Behavior Survey. Any adolescent complaining of suicidal intent or who has made a suicide attempt must be evaluated carefully for the presence of a depressive disorder (DD).
Risk Factors for Adolescent Depression
A multitude of “risk factors” have been identified for adolescent depression. However, it has been difficult to separate risk factors which are highly predictive (causal) from associated factors.
Highly Predictive Risk Factors
Associated Risk Factors
In “real life” cases it may be difficult to determine the nature of the risk factors identified.
For example, a depressed teen may have a depressed parent and also live in a family where conflict and poor affective support exist. It is hard to determine if the causal factor is the genetic risk passed on through the depressed parent or the environment which itself may be the result of parental depression, or both.
In addition, studies are just now beginning to help differentiate proximal versus distal risk factors.
Proximal Risk Factors
If the clinician is aware that the teenager has a positive family history of MDD or bipolar disorder, “preventive counseling” in the prepubertal period may help the parent and teen identify significant mood disturbances should they arise. If such mood disturbances are identified, the parent and teen will to be better prepared to seek clinical attention early.
Distal Risk Factors
Negative Life Events
Negative life events are commonly but often mistakenly considered to be causal risk factors for adolescent depression.
These events include but are not limited to breakup of a romantic relationship, school problems, geographic moves, or family difficulties. The reality is that these life events are so common among adolescents that if they were causal, every teenager would be clinically depressed. These events however may lead to distress, depressive symptoms, and even demoralization but are not likely to be single substantive causal factors for MDD. Another difficulty in exploring the impact of negative life events on MDD is understanding the timing of the onset of depression in adolescents. Typically, DDs are not known to have a sudden onset; instead, they have a gradual and insidious onset. In fact, the onset is often so gradual, that the associated dysfunction can be overlooked. It is not uncommon for the gradual onset of the DD (and not yet identified) to lead to significant life events such as interpersonal problems, family difficulties, romantic breakups, and a variety of school difficulties. Following these events, the depression may become more clearly manifest. Therefore, events which may be identified as “causal” for a depressive episode may actually be the result of the episode itself.
The diagnosis of depression is made using DSM-IV-TR criteria (American Psychiatric Association, 2000) or the International Classification of Diseases (ICD) criteria (World Health Organization, 1992). In the United States, the DSM criteria are most commonly used. The DSM classifies three types of DDs:
There is good consensus about the diagnostic categories of MDD and Dysthymic disorder. There is less consensus about the category of DD-NOS. In the opinion of the authors of this chapter, the DD-NOS diagnosis should not be used to justify medical interventions in this age-group.
DSM Criteria for MDD
In order to meet DSM criteria for MDD, the young person must have experienced one or more major depressive episodes (MDEs) without ever having experienced a manic, mixed, or hypomanic episode.
Diagnostic Criteria for a Major Depressive Episode (Adapted from DSM-IV-TR)
For at least 2 consecutive weeks the adolescent has experienced five (or more) of the following symptoms which represent a change from previous functioning; one of the symptoms must be either depressed or irritable mood or markedly diminished interest or pleasure.
In addition to the symptom complex described earlier, the following must also be present:
If all of the aforementioned conditions are not met, then the adolescent does not meet the diagnosis for a MDE.
Some youth may experience long-standing and persistent depressive symptoms that are not demoralizing and cause functional difficulties. These youth may be demonstrating DD which is a chronic mood disturbance characterized by depressive symptoms that are present most days for at least a period of 1 year.
Diagnosis of Dysthymic Disorder (Adapted from DSM-IV-TR)
In neither MDD nor Dysthymic disorder can the symptoms be part of a schizophrenic, schizoaffective, bipolar, or delusional illness. The two DDs described here may have a seasonal component. It is important to note that should there be a seasonal component present this does not affect diagnosis or treatment of the disorder.
Identifying the Depressed Adolescent
Underrecognition of clinical depression in teens is common in primary care (Asarnow et al., 2002; Rushton et al., 2002). This may be in part due to the different clinical presentation of depression in teens as compared to adults (youth may present with marked irritability rather than sad or depressed mood) and may be compounded by the hesitance of teens to self disclose symptoms of depression if not asked directly about these symptoms during a clinical assessment.
It is reasonable for clinicians to screen for depression, because it is one of the most common medical disorders that begin in the teenage years. Screening tests include the Kutcher Adolescent Depression Scale, the KADS-11
(an 11-item version of the KADS self-report questionnaire), the Beck Depression Inventory (Beck and Steer, 1987), the Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1987), and the Mood and Feelings Questionnaire (Thapar and McGuffin, 1998). Most of these take longer to administer than the six-item KADS and their sensitivities and specificities range from 0.70 to 0.90 and 0.39 to 0.90, respectively.
Some general health screening tools for adolescents have been studied in primary care. These include the Patient Health Questionnaire for Adolescents (Johnston et al., 2002) and the Safe Times Questionnaire (Schubiner et al., 1994). Screening tools in the primary care setting is strongly recommended, as the evidence suggests that sole reliance on a teenager's reporting of depression as a chief complaint may miss a significant number of depressed youth (Zuckerbrot and Jensen, 2006).
Although not a screening tool, The Chehil and Kutcher Clinical Assessment of Adolescent Depression (CAAD, See Fig. 78.3) is designed to accompany the 11-item version of the KADS. Additional items found in the CAAD that are not present in the KADS-11 include assessment of current substance use and an overall rating of symptoms, function and safety.
Scores on the 11 items in the KADS are reviewed for both the following:
On the basis of the information obtained from the teen and the informant, the clinician also provides a “composite” rating for each symptom using the same four-point scale. The CAAD can be used effectively by the clinician to conduct a detailed clinical interview needed to arrive at a diagnosis of MDD.
Bipolar Disorder (Manic Depression)
If MDD occurs together with mania the diagnosis is bipolar disorder. This illness usually has its onset approximately 10 to 15 years postpuberty and is a chronic psychiatric disorder characterized by periods of depressed mood (which meet the criteria of MDD described earlier) and periods of significantly elevated mood (mania). Mania is characterized by intense energy, hyperactivity, elation, grandiosity, sleeplessness, racing thoughts, pressured speech, excessive risk-taking behaviors, excessive impulsive behaviors (such as spending sprees without the means to pay), and hypersexuality. In most teens with bipolar disorder, a “classic” MDE may be the first presentation of the illness; the initial diagnosis of MDD is revised after the first clear manic episode has been experienced. In some teenagers, an antidepressant medication can precipitate the development of a manic episode. While the following clinical points may be of help in identification of individuals at higher risk of bipolar disorder, at the present time we have no effective way of accurately predicting which teen presenting with MDD will go on to develop a bipolar disorder. The clinical points listed in the next section may be of help in identifying teens at higher risk of bipolar disorder.
Clinical Risk Factors for Bipolar Disorder in a Clinically Depressed Teenager
FIGURE 78.1 Six-Item Kutcher Adolescent Depression Scale. (The Six-Item KADS is under copyright to Dr. Stan Kutcher. Use is with written permission only. Individuals wishing to use the six-item KADS can contact Dr. Kutcher at firstname.lastname@example.org for permission.)
FIGURE 78.1 (Continued)
FIGURE 78.2 11-Item Kutcher Adolescent Depression Scale. (The 11-Item KADS is under copyright to Dr. Stan Kutcher. Use is with written permission only. Individuals wishing to use the 11-item KADS can contact Dr. Kutcher at email@example.com for permission.)
FIGURE 78.2 (Continued)
FIGURE 78.2 (Continued)
FIGURE 78.3 Chehil and Kutcher Clinical Assessment of Adolescent Depression. (The Clinical Assessment of Adolescent Depression is under copyright to Dr. Sonia Chehil and Dr. Stan Kutcher. Use is with written permission only. Individuals wishing to use the CAAD can contact Dr. Chehil at firstname.lastname@example.org or Dr. Kutcher at email@example.com for permission.)
FIGURE 78.3 (Continued)
FIGURE 78.3 (Continued)
FIGURE 78.3 (Continued)
FIGURE 78.3 (Continued)
A diagnosis of bipolar disorder is not to be made lightly. Concerns have been raised with recent increases in the use of a variety of thymoleptic medications (e.g., lithium, valproate) and antipsychotics (e.g., olanzapine, risperidone) to treat “bipolar spectrum” disorders in this age-group. Such interventions are not benign and carry risks of significant side effects. The use of these compounds by health care professionals in teens who demonstrate mood lability or persistent behavioral disturbances, but who do not meet rigorous DSM diagnostic criteria for bipolar disorder, is not encouraged. These interventions should be reserved for use in those disorders where these medications have been clearly demonstrated to be effective.
Anxiety symptoms which are mild, transient, and not associated with significant impairment are common in the adolescent population. However, many young people experience symptoms of anxiety that are severe and significantly affect their ability to function at school, in recreational activities, at home, in their relationships, or with their peers. As with clinical depression, teens who have anxiety disorders must experience certain clearly demarcated symptoms for a specified amount of time, which are associated with impaired function or significant distress. The diagnosis of an anxiety disorder is made using the DSM-IV-TR (American Psychiatric Association, 2000) or the ICD criteria (World Health Organization, 1992). There are a number of different yet related anxiety disorders which commonly occur during the adolescent years. These anxiety disorders include generalized anxiety disorder (GAD), social anxiety disorder (SAD) (also known as social phobia), panic disorder (PD), and obsessive compulsive disorder (OCD). Post-traumatic stress disorder (PTSD) may also occur in teenagers given the proper confluence of circumstance and constitution. Coexisting depressive symptoms are common and many teens may fulfill criteria for both depressive as well as anxiety disorders. In terms of the anxiety disorders themselves, these also often co-occur.
Generalized Anxiety Disorder
GAD is characterized by uncontrollable, excessive, and unrelenting worry that is inappropriate and not restricted to particular events or situations but rather involves many “usual” things such as safety of self and others, being on time, school work, performance, or illness. The worrying leads to significant emotional distress and functional impairment. Adolescents with GAD often also experience irritability, difficulty concentrating, and restlessness as well as many physical symptoms of anxiety such as recurrent headaches, stomach upset, muscle tension, fatigue, and sleep disturbance. Teens with GAD may experience social exclusion or bullying.
The onset of PD often occurs in mid to late adolescence and is characterized by recurrent, unexpected, rapid onset, time limited, intense episodes of severe anxiety (panic attacks) occurring in a crescendo–decrescendo pattern usually peaking within 10 minutes and lasting 30 to 45 minutes. Panic attacks are associated with autonomic hyperarousal, respiratory and cardiac distress, and cognitions of dread and fear. Adolescents with PD also experience anticipatory anxiety (the teen fears having an attack) between panic attacks as well as phobic avoidance (the teen avoids locations in which panic attacks occurred). Severe cases of PD can lead to agoraphobia.
Social Anxiety Disorder
SAD is characterized by excessive fears of social situations (e.g., public speaking, going to a party, standing up in class, changing in the locker room) in which the teen thinks that they are the subject of negative scrutiny by others. They feel embarrassed and anxious and may even experience panic attacks when faced with the dreaded social situation. They avoid or tolerate (with extreme difficulty) the feared situations and as a result experience social, interpersonal, and academic/vocational impairment. SAD in teens may be associated with school refusal or avoidance.
Obsessive Compulsive Disorder
OCD is characterized by the presence of recurrent, intrusive, unwanted thoughts or images that the teen knows are not true (e.g., “my hands are covered with deadly germs”) calledobsessions and/or repetitive physical or mental rituals (e.g., counting, ordering, washing) called compulsions. These symptoms create significant emotional distress and lead to functional impairment.
Post-Traumatic Stress Disorder
PTSD may occur in young people who are exposed to severe stressors that violate their personal safety (such as assault or rape) or in those who have witnessed or experienced a horrific event (traffic accident death, murder) or natural disaster (hurricane, earthquake). In addition to functional impairment, PTSD symptoms include reexperiencing the event (e.g., through dreams, flashbacks, vivid memories), persistent avoidance of situations or persons associated with the event, or increased hyperarousal. PTSD must be distinguished from the acute stress reaction which is a normal response to severe stressors and resolves over a period of a few months without clinical intervention.
Epidemiology of Anxiety Disorders
Anxiety disorders are very common in adolescents. At any one time up to one third of youth in the community may suffer from one of the anxiety disorders (Costello et al., 2005). Retrospective reports of adults with anxiety disorders suggest that the onset of anxiety disorders generally begin in childhood or adolescence. The incidence of anxiety disorders is greater in girls than boys, and girls tend to have an earlier age at onset than boys.
Risk Factors for Adolescent Anxiety Disorders
Like DD, anxiety disorders tend to run in families. A family history of parental anxiety or mood disorder has been
shown to be a risk factor for an adolescent anxiety disorder. Other risk factors for the development of anxiety disorders include female gender, inhibited or anxious temperament, anxiety sensitivity, increased startle reflex, and increased autonomic reactivity (Merikangas, 2005; Costello et al., 2005).
Laboratory Evaluation for Depression and Anxiety
There are no diagnostic or laboratory tests that can be used to establish a diagnosis of depression or anxiety. Both depression and anxiety disorders are “clinical diagnosis” requiring the clinician to rely on current and longitudinal symptoms elucidated from the patient and informants where appropriate. All teens suspected of having one of these disorders should have a careful medical history and physical examination to rule out the presence of an underlying or contributing medical disorder. “Screening” tests for medical conditions which may present with depressive or anxiety symptoms such as thyroid stimulating hormone for hypothyroidism or thyroxine for hyperthyroidism are not cost-effective given their low positive predictive value in this population. If there is evidence from the history or physical examination to suggest the presence of a particular medical condition, the appropriate laboratory investigations should be carried out to confirm or reject the diagnostic possibility. Once a diagnosis of a DD or anxiety disorder is confirmed, a pregnancy test in adolescent females may be indicated if medication treatment is being considered.
Once the diagnosis has been made, a proper baseline evaluation of the depressed or anxious adolescent must be conducted. This includes a measure of symptom severity and a measure of functional impairment. In addition, a baseline evaluation of somatic symptoms and psychoeducation should be conducted.
Symptom severity is best measured using an observer rated tool. For the depressed teen, the CAAD (Fig. 78.3) provides a useful clinical tool for measuring the severity of depressed symptoms in a teenager. It can also be repeatedly applied over the course of treatment to measure treatment response. Similar tools for anxiety disorders include the Screen for Child Anxiety Related Emotional Disorders (SCARED) or the Pediatric Anxiety Rating Scale (Birmaher et al., 1999; Research Units on Pediatric Psychopharmacology Study Group, 2002).
A simple, clinically meaningful, and easily applied measure of overall functional impairment is a four-point scale to ascertain the composite level of impairment as a summary of difficulties experienced in each of the following domains—family functioning, school functioning, work functioning, peer functioning, and recreational functioning. For each functional domain the following scoring system is suggested:
It is not unusual for adolescents with DDs or anxiety disorders to experience markedly poor functioning in one or two domains and moderately impaired functioning in others. In such situations, the domain(s) with the most impairment should be identified for particular attention.
A clinically useful tool that can be routinely used to measure a depressed or anxious teen's functioning at baseline and during treatment is the Clinical Measurement of Functioning in Adolescent Depression and Anxiety Disorders (Table 78.2).
Evaluation of Somatic Symptom Side Effects
Somatic symptoms should be systematically assessed at baseline and at appropriate intervals during treatment. Such an assessment will provide the clinician and the patient with useful information about which physical complaints are actually treatment emergent side effects and which are more likely to be somatic manifestations of the depressive syndrome or the anxiety disorder.
A simple but clinically useful side-effect tool such as the one found in Table 78.3 can be used at baseline and repeated at each clinic visit. A four-point scoring system as described in the subsequent text can be used to evaluate each somatic complaint:
Educating the teenager and the parents or guardians about the disorder and its treatment is a necessary part of the baseline evaluation. After an informed discussion, the treatment for the depression and the relevant anxiety disorder should be determined by consensus with all interested parties. Ongoing individual and family support will be needed. The adolescent and parents will benefit from practical advice on how to approach common problems. Clinician intervention with the school system is often indicated, especially if grades are a problem or behavioral difficulties have been identified by school officials.
An appropriate period of psychoeducation before starting treatment is time well spent in the care of the depressed or anxious teenager. When properly conducted, it may serve to help establish a positive therapeutic relationship that will underlie whatever interventions are to follow. There is no rush to begin treatment (either medication or psychotherapy), as the only indication for emergency intervention is risk of self-harm or suicide (in which case hospitalization is required). A week to 10 days from time of diagnosis to the initiation of treatment will provide an opportunity for the teen and parents to read about the disorder and its treatments and to raise any issues that may come up. In addition to direct discussions, the clinician should have available scientifically valid literature on the topics and should direct the patient and family to appropriate Web sites for their own research.
Evidence-Based Treatments for Adolescent Depression and Anxiety Disorders
Current scientific evidence supports only a few interventions as having therapeutic efficacy for adolescent depression and anxiety disorders—SSRI medications (particularly fluoxetine and possibly sertraline or citalopram), psychological treatments (cognitive behavioral therapy [CBT], and interpersonal therapy [IPT]) (Harrington et al., 1998; Mufson et al., 2004;Ryan, 2005; AACAP, 2002; Waslick, 2005).
For adolescent depression, the best available scientific evidence favors fluoxetine (March et al., 2004) as the single best intervention and fluoxetine combined with CBT as the best intervention overall (March et al., 2004). Regardless of the intervention chosen, clinicians should be aware that the placebo response rates in the treatment of adolescent depression range from approximately 35% to 50%. The placebo response rate in the treatment of adolescent anxiety disorders appears to be lower than that seen in depression. Recent research suggests that the previous enthusiasm for the effectiveness of specific psychotherapies (CBT and IPT) in adolescent depression may have been overrated (National Institutes of Mental Health Meeting, 2006).
Both SSRIs and CBT have individually been found to be effective strategies in the treatment of a variety of anxiety disorders including GAD, SAD, and OCD. Unfortunately, there are no comparative studies addressing whether CBT or SSRI treatment alone is superior or whether combining the two treatment options has any added benefit for most of the anxiety disorders with the exception of OCD. The evidence for the treatment of OCD has shown that the combination of fluvoxamine with CBT or fluoxetine and CBT is superior to either alone. In general, the benefits of CBT for anxiety disorders are better than those found in the treatment of depression.
For adolescents with mild symptoms of depression and minimal functional impairment, a period of watchful monitoring following psychoeducation may be considered. A similar approach can be used with any of the anxiety disorders. This should include regular telephone contact, frequent face to face visits, and supportive problem-based counseling. Continuous evaluation of suicidality is required. If this does not lead to substantial symptom resolution over a period of 4 to 6 weeks, more intensive medical or psychological intervention is indicated.
For adolescents presenting with moderate to severe depressive symptoms accompanied by functional impairment, the initiation of medication or psychological treatments is indicated. This recommendation is similar for teenagers presenting with anxiety disorders. In some cases, the primary care clinician may not be trained to carry out CBT. If this is the case and referral for this intervention is not timely or possible, the use of cognitive therapy techniques (such as challenging dysfunctional thoughts and “all or none” reasoning) can be applied as part of ongoing support while medications are being prescribed. In all cases, ongoing monitoring of suicidality is required. Both at baseline and throughout treatment, the clinician should also address the issue of drug or alcohol use, abuse or dependence, as both depression and anxiety disorders increase the risk of substance abuse in young people.
If a depressed adolescent presents with psychotic symptoms or the clinician is concerned that there may be a psychotic disorder or bipolar illness underlying the depressive presentation, referral to an appropriate mental health professional for a thorough diagnostic assessment and perhaps hospitalization may be necessary. Suicidal intent or suicidal actions require a hospital admission to maintain safety and to provide immediate stabilization and proper evaluation.
While the recent controversies about SSRI medications causing suicide have been played out in the popular press, multiple independent investigations of the data by qualified
groups and individuals have sufficiently addressed this issue and shown that SSRI use has not been associated with an increased risk of completed suicide. On the contrary, by playing a significant role in the treatment of teen depression, SSRI treatment may be protective and lead to a reduction in teen suicide. Recent prospective data (March et al., 2004) shows that the initiation of treatment with fluoxetine alone significantly decreases suicidality. Further, a health plan record analysis of SSRI use demonstrated a highly significant decrease in suicidality following the initiation of SSRI treatment in adolescents compared with the period before SSRI treatment (Simon et al., 2006). However, compared to placebo, SSRIs are associated with an increase in suicidal ideation and self-harm behaviors (but not completed suicide) (Cheung et al., 2005, 2006). As a result, the U.S. Food and Drug Administration (FDA) has issued a “black box” warning to advise consumers that these medications can cause these behaviors.
This data notwithstanding, prescribing clinicians require a good understanding of the pharmacokinetics and pharmacodynamics of these medications. This includes understanding the various physical and behavioral side effects that can be experienced as a result of the medication treatment. The most concerning of these behavioral side effects is enhanced suicidality (suicidal thinking) and possibly self-harm behaviors which can occur soon after the initiation of antidepressant treatment. Other behavioral adverse effects such as impulsivity, hostility, and restlessness can also be experienced by some patients. It is essential that the clinician inform the patient and family about the possibility of adverse effects, provide appropriate monitoring, and work out a contingency plan with the patient and family should the patient experience these adverse effects (Kutcher et al., 2004).
Individual Medication Categories
Selective Serotonin Reuptake Inhibitors
The SSRI medications, particularly fluoxetine, sertraline, and citalopram, have the best overall evidence supporting their use in the treatment of adolescent depression and anxiety disorders (Cheung et al., 2005; Wagner, 2005; Ryan, 2005). These medications work by blocking the reuptake of serotonin in presynaptic neurons. Doses for older adolescents parallel those of adults, whereas younger adolescents are generally started at lower doses and titrated upward more slowly. The advantages of the SSRIs are as follows:
Overall these medications are well tolerated and safe, with a much lower risk in overdose situations. However, there are also some disadvantages to consider:
Given the available evidence, it is not possible to recommend the use of venlafaxine, nefazodone, monoamine oxidase inhibitors, or any tricyclic antidepressant (TCA) in adolescents. Randomized controlled trials (RCTs) of venlafaxine and TCAs have not shown these compounds to be significantly better than placebo in treating depressed adolescents younger than 18 or 19 years. While there is evidence for efficacy in adults, the number of individuals aged 18 to 25 in these studies is very small and therefore it is difficult to assess efficacy and safety in the young adult population. The FDA data base on child and adolescent pharmacotherapy identified that venlafaxine was the antidepressant most likely to be associated with suicidality in this age-group. The TCAs are known to have more cardiotoxic side effects than the SSRIs. Both these medications lack substantive evidence of efficacy, and the increased risk of use suggests that neither venlafaxine nor a TCA should be used in this population. Similarly, no RCT evidence for the efficacy, safety, and tolerability of Monoamine-oxidase inhibitor (MAOIs) exists in the teen population. The expected risk-benefit ratio of these compounds does not support their use in adolescent depression. Finally, nefazodone has not been demonstrated to be more effective than placebo treatment in this age-group. Bupropion may be considered as a second-line medication as there is theoretical rationale and some clinical evidence that this medication may be useful in teenagers with MDD who have comorbid attention-deficit hyperactivity disorder (ADHD).
Mechanism of action: Bupropion is a dopamine reuptake inhibitor with some norepinephrine reuptake inhibition as well. It has stimulant–like properties, is well tolerated and may be particularly beneficial for patients with depression and significant psychomotor retardation. Bupropion is available in both regular-release as well as sustained release formulations. Only the sustained release formulation should be used for young people.
Disadvantages of regular release bupropion
Although not well studied, clinical experience and some open label studies suggest that low doses of the benzodiazepine clonazepam (0.25–1 mg b.i.d.) may be of value in some of the anxiety disorders (such as PD). Some adolescents may experience a paradoxical response to a benzodiazepine characterized by agitation, insomnia, and disinhibition. If a benzodiazepine is to be used in teens, the clinician must look out for the occurrence of this paradoxical response and must inform the patient and caregivers that this might occur. Rapid onset, short-acting benzodiazepines should be avoided. Long-term use of benzodiazepines is
generally not recommended and rapid discontinuation should be avoided whenever possible.
Antipsychotic Medications and Mood Stabilizers
Antipsychotic medications or mood stabilizers should not be used as first-line treatments for either depression or anxiety disorders. They may have some utility in highly specific and limited circumstances, for example, with psychotic depression or for treatment-resistant OCD where they can be used to augment antidepressants. Such augmentation strategies should be preceded by appropriate subspecialist consultation.
Comfort with prescribing and monitoring antidepressant medications stem from knowledge and familiarity. An effective strategy to use in clinical practice is to choose a couple of antidepressant medications with demonstrated safety and efficacy in teens and use these compounds preferentially (Ambrosini et al., 1995). In this way, the clinician will become familiar with the range of effects that these compounds exhibit at different doses and in different individuals. Continued use of a small number of different medications will enable the clinician to build up an expertise with these medicines over time. Furthermore, given the available evidence pertaining to treatment effects of the SSRI compounds, the knowledge of two of these medications will be sufficient. On the basis of available literature, in order of preference, fluoxetine, citalopram, and sertraline would be reasonable SSRIs to choose. Table 78.4 provides a dosing guide using two of these SSRIs as an example for clinicians. Table 78.5 lists common SSRI medications and other antidepressant medications, including doses and side effects. Teens with anxiety disorders may be sensitive to the side effects of the SSRIs, particularly the activation side effects which generally occur early on in treatment.
Patient Treatment and Monitoring Model
The model described in the subsequent text identifies the primary care practitioner as providing most of the care with ongoing consultation from the psychiatric specialist.
If Medication Treatment is to be Initiated
Monitoring Throughout the Course of Treatment
Anecdotal evidence and some limited research suggest that light therapy may be a potentially useful adjunct to other interventions for adolescent depression occurring in the winter months. Electroconvulsive therapy (ECT) may be indicated in very specific circumstances (psychotic depression) and should be provided by experts only under highly controlled conditions. There is no rationale for using ECT in the treatment of anxiety disorders. Transcranial magnetic stimulation and other biological treatments have not been well studied in this population.
Adolescent depression and anxiety disorders are significant public health problems. Adolescent depression can cause a high degree of morbidity and significant mortality usually due to suicide. Adolescent anxiety disorders can be significantly disabling and may be associated with substance abuse and other chronic life difficulties. Effective treatments are available and when properly administered can be helpful in the primary care setting. Evidence-based interventions should be used to guide treatment. Ongoing careful monitoring of therapeutic effectiveness and the presence of adverse events within the context of a supportive and trusting relationship is the cornerstone of effective treatment.
Primary care clinicians are in a unique position to develop and implement a treatment plan for the depressed teenager. Clinicians treating depressed adolescents will need to be well versed in the effective medication options available. To date, the SSRIs (specifically fluoxetine, citalopram, and sertraline) are the only class of antidepressant medications that have been shown to be safe and effective in treating depression in adolescents. In addition, fluvoxamine has proven effect in OCD. Careful monitoring of medication treatment and the judicious application of psychotherapeutic strategies is necessary.
For Teenagers and Parents
http://www.aacap.org/about/glossary/depress.htm. American Academy of Child and Adolescent Psychiatry.
http://www.nmha.org/infotr/factsheets/24.cfm. National Mental Health Association fact sheet and other information on adolescent depression.
http://www.nlm.nih.gov/medlineplus/depression.html. National Library of Medicine information regarding adolescent depression.
http://www.nimh.nih.gov/HealthInformation/anxietymenu. cfm. National Institutes of Mental Health information on anxiety disorders.
http://www.samhsa.gov/. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration information on adolescent anxiety disorders.
http://www.dbsalliance.org/. US Department of Veterans Affairs, National Center for PTSD information on PTSD in children and adolescents.
References and Suggested Readings
AACAP. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2002;37(10 Suppl):63S.
Ambrosini PJ, Emslie GJ, Greenhill LL, et al. Controversies and opinions: selecting a sequence of antidepressants for treatment depression in youth. J Child Adolesc Psychopharmacol 1995;5(4):233.
American Academy of Pediatrics, Committee on Adolescence. Suicide and suicide attempts in adolescents. Pediatrics 2000;105:871.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed (Text Revision) DSM-IV-TR. Washington, DC: American Psychiatry Association; 2000.
Asarnow JR, Jaycox LH, Anderson M. Depression among youth in primary care models for delivering mental health services. Child Adolesc Psychiatr Clin N Am 2002;11:477.
Beck AT, Steer RA. Manual for the beck depression inventory. San Antonio, TX: The Psychological Corporation; 1987.
Birmaher B, Brent D, Chiapetta L, et al. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry 1999;38:1230.
Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996a;35:1427.
Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part II. J Am Acad Child Adolesc Psychiatry 1996b;35:1575.
Brooks S. The Kutcher Adolescent Depression Scale (KADS). Child Adolesc Psychopharmacol News 2004;9(5).
Brooks S, Krulewicz S, Kutcher S. The kutcher adolescent depression scale: assessment of its evaluative properties over the course of an 8-week pediatric pharmacotherapy trial.J Child Adolesc Psychopharmacol 2003;23:239.
Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2005. Morb Mortal Wkly Rep CDC Surveill Summ 2006;55(SS05):1.
Cheung Am, Emslie G, Mayes T. Review and safety and efficacy of antidepressants in youth with depression. J Child Psychol Psychiatry 2005;46(7):735.
Cheung A, Emslie G, Mayes T. The use of antidepressants to treat depression in children and adolescents. Can Med Assoc J 2006;174:193.
Costello EJ, Egger HL, Angold A. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Child Adolesc Psychiatr Clin N Am2005;14:631.
Hammad TA. Results of the analysis of suicidality in pediatric trials of newer antidepressants. Presentation at the Food and Drug Administration, Psychopharmacologic Drugs Advisory Committee and the Pediatric Advisory Committee. 13 September, 2004.
Harrington R, Whittaker J, Shoebridge P, et al. Systematic review of efficacy of cognitive behaviour therapies in childhood and adolescent depressive disorder. BMJ 1998;316 (7144):1559.
Hazell P, O'Connell D, Healthcote D, et al. Tricyclic drugs for depression in children and adolescents. Cochrane Database Syst Rev 2002;2:CD002317.
Johnston JG, Harris ES, Spitzer Rl, et al. The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health 2002;30:196.
Kessler RC, Avenevoli S, Ries Merikangas K, et al. Mood disorders in children and adolescents: an epidemiologic perspective. Biol Psychiatry 2001;15:1002.
Kutcher S, Gardiner D, Virani A. A clinical Approach to Treating Major Depressive Disorder with SSRIs in Adolescents: 12 Steps to Careful Monitoring. Child and Adolescent Psychopharmacology News. 2004;9(5):1.
LeBlanc JC, Almudevar A, Brooks S, et al. Screening for adolescent depression: comparison of the kutcher adolescent depression scale with the beck depression inventory. J Child Adolesc Psychopharmacol 2002;12:113.
March JU, Silva S, Petrycki S, et al. Treatment for Adolescents with Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 2004;292(7):807.
Merikangas KR. Vulnerability factors for anxiety disorders in children and adolescents. Child Adolesc Psychiatr Clin N Am 2005;14:649.
Mufson L, Dorta KP, Wickramaratne P, et al. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry 2004;61(6):577.
Myers K, Winters N C. Ten-year review of rating scales, VII: scales assessing functional impairment. Journal Of The American Academy Of Child Adolescent Psychiatry. 2002;41(6):634.
National Institutes of Mental Health Meeting. Treating children and adolescents with depression: what we know and what else we need to know through research. Washington, February 6 and 7, 2006.
Olfson M, Shaffer D, Marcus S. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 2003;609:978.
Research Units on Pediatric Psychopharmacology Study Group. The pediatric anxiety rating scale (PARS): development and psychometric properties. J Am Acad Child Adolesc Psychiatry 2002;41:1061.
Reynolds WM. Reynolds adolescent depression scale. Odessa, FL: Psychol Assess Resour; 1987.
Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med 2002;156:592.
Ryan ND. Treatment of depression in children and adolescents. Lancet 2005;366:933.
Schubiner H, Tzelpis A, Podany E. The clinical utility of the Safe Times Questionnaire. J Adolesc Health. 1994 Jul;15(5):374–82.
Schubiner H, Tzelpis A, Podany E. The clinical utility of the safe times questionnaire. J Adolesc Health Care 1994;15:374.
Shaffer D, Craft L. Methods of adolescent suicide prevention. J Clin Psychiatry 1999;60(2 Suppl):70.
Simon GE, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry 2006;163:41.
Thapar A, McGuffin P. Validity of the shortened mood and feelings questionnaire in a community sample of children and adolescents: a preliminary research note. Psychiatry Res1998;81:259.
US Food and Drug Administration. Antidepressant use in children, adolescents and adults. http://www.fda.gov/cder.drug. antidepressants/default.htm. Accessed Nov. 25, 2005.
Vitiello B, Calderoni D, Mazzone L. Pharmacologic treatment of children and adolescents with major depressive disorder. In Vitiello B, Masi G, Maarazziti D. Handbook of child and adolescent psychopharmacology. Abingdon, UK: Informa Healthcare; 2006:53.
Wagner KD. Pharmacotherapy for major depression in children and adolescents. Prog Neuropsychopharmacol Biol Psychiatry 2005;29:819.
Waslick B. Psychopharmacology interventions for pediatric anxiety disorders: a research update. Child Adolesc Psychiatr Clin N Am 2005;15:51.
Weber S. Factor structure of the Reynolds Adolescent Depression Scale in a sample of a school-based adolescents. J Nurs. Meas. 2000 Summer;8(1):23–40.
Whittington C, Kendall T, Fongay P. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet2004;363:1341.
World Health Organisation, International statistical classification and related health problems: ICD-10. Geneva, 1992–1994.
World Health Organization. Caring for children and adolescents with mental disorders: Setting WHO Directions. Geneva: WHO; 2003.
Zuckerbrot RA, Jensen PS. Improving recognition of adolescent depression in primary care. Arch Pediatr Adolesc Med 2006;160:694.