2005-2009
Statewide Comprehensive Plan for Mental Health Service Services
Chapter 6: Children and Depression
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Background
Child and adolescent depression and bipolar disorder, also known as mood disorders,
are serious medical illnesses that affect more than 20 million Americans of
every race and ethnic group.1 Mood disorders are considered to be
brain disorders because they are mediated through the brain. These illnesses
affect individuals at all stages of life, including childhood. If left untreated,
mood disorders can be fatal: nearly one in six persons with severe untreated
depression will die by suicide.2,3 According to the WHO
and the World Bank, major depression is the leading cause of disability in the
U.S. and other countries with developed economies.4 Because of the
profound public health consequences associated with these disorders, OMH is
committed to improving the recognition, early intervention, and treatment of
mood disorders in children and youth.
Among the most significant scientific advances in the last three decades has
been the discovery that depression and bipolar disorder not only exist in children
but are as debilitating for them as they are for adults. Major depression affects
an estimated 6% of children ages 9-17.5 As children become adolescents,
it becomes more common in girls than in boys.6 Epidemiological data
are lacking on the extent to which bipolar disorder affects children, but early
indications suggest that some proportion of children and adolescents who have
major depression will be found to have bipolar disorder later in life. The likelihood
increases if the depressed child has a family member with bipolar disorder.7
Recent scientific advances from neuroscience, genetics and clinical trials have demonstrated that the brain is the primary organ affected in depression and bipolar disorder. Modern brain imaging technologies have revealed neural circuits responsible for the regulation of moods, thought, sleep, appetite and behavior. When these circuits fail to function properly, critical neurotransmitters-chemicals used by nerve cells to communicate-are often out of balance. Recent work has delineated several neurotransmitter and other neurochemical systems that are involved in mood disorders, including systems that modulate gene transcription. These discoveries provide clues to potential neurochemical targets for effective treatments. In addition, genetics research indicates that vulnerabilities to depression and bipolar disorder often result from the interaction of multiple genes and environmental factors. Numerous treatment studies are currently under way to examine brain chemistry and the mechanisms of action of both psychosocial and pharmacologic treatments to improve the efficiency and effectiveness of these interventions.
What are the Symptoms of Depression and Bipolar Disorder in Children
and Adolescents?
Unlike normal changes in mood that are common among most individuals at different
times of life, the symptoms of depression are extreme and often incapacitating.
The symptoms include a persistent sad mood; loss of interest in activities;
significant change in appetite or body weight; difficulty sleeping or oversleeping;
physical slowing or agitation; loss of energy; feelings of worthlessness; difficulty
thinking or concentrating; and recurrent thoughts of death or suicide. A diagnosis
of depression occurs if an individual has five or more of these symptoms every
day during a two-week period. In bipolar disorder, an extremely debilitating
illness, episodes of depression alternate with periods of persistently elevated
mood or irritability, sometimes accompanied by a decreased need for sleep, increased
talkativeness, racing thoughts, distractibility or extreme physical agitation.
The consequences of untreated depression can be devastating. A 2004 report from
the American Academy of Child and Adolescent Psychiatry documented that suicide
is the third leading cause of death for 15 to 24 year olds, and the sixth leading
cause of death for five to 14 year olds. In fact, in 2001 nearly 4,000 teenagers
between the ages of 15 and 24 killed themselves.8 Depression is responsible
for over 500,000 suicide attempts by children and adolescents a year.9
How and When Does Depression Develop in Children?
Puberty appears to be the time at which children, and in particular girls, are
at increased risk for developing depression. The changing levels of hormones
that occur during puberty may affect brain function. There is some evidence
that exposure to increased levels of hormones at puberty, particularly under
conditions of social stress, can predict heightened risk for depression.
Depression among children or adolescents is often preceded by other mental disorders,
most notably anxiety. Anxiety disorders are eight times more common in depressed
than non-depressed children and adolescents, while behavioral problems (e.g.,
conduct disorders and oppositional disorders) are six times more common. Attention
Deficit Hyperactivity Disorder (ADHD) is five times more common among youth
with depression than youth unaffected by it. In fact, the onset of depression
usually follows the onset of other disorders. Consequently, prevention of depression
is directly linked to the prevention or treatment of these other psychiatric
disorders.
Depression is also significantly associated with abuse, maltreatment and trauma. Stress exposure, as has been well documented in both animal and human studies, can produce persistent effects on brain structure and function. For example, in animal studies, exposure to extreme adversity during critical periods of development leads to changes in perceptions of and responsiveness to environmental events. The interactions among stress exposure, genetic vulnerabilities, and development are complex and these interactions are still being examined. However, effective treatments for stress-related disorders in young persons, particularly trauma, exist and have been studied for more than a decade. It is likely that providing early and effective interventions to children who have been exposed to abuse, maltreatment or trauma may improve their long-term outcomes by providing them with necessary coping strategies for handling subsequent stressors and decrease the likelihood that they will develop severe depression later in life.
Other risk factors for early-onset depression include family history. Children of parents with depression are three times more likely to have an episode of depression during their lifetime than children of parents without depression. Recent findings from a three-generation study of familial depression documented significantly increased risk of mental disorders among grandchildren in families where individuals in two generations have experienced depression, with almost 60% of these grandchildren having mental disorders.10 Furthermore, this intergenerational study documented that anxiety was a clear precursor of depression and that grandchildren of depressed parents and grandparents were at a significantly elevated risk for anxiety disorders. The findings from this study strongly suggest that early interventions for children with a family history of depression are especially warranted.
Clinical practice guidelines to improve identification of adolescents with depression for primary care providers have recently been developed through a consensus process.11 The resulting Guidelines for Treatment of Adolescent Depression are intended for use by primary care professionals for the management of adolescents with or at risk for depression who are between the ages of ten and 21. Using a combination of evidence- and consensus-based methodologies, the guidelines were developed in six phases to assist in primary care management. The phases include: 1) identification/surveillance of youth at risk for depression, 2) assessment and diagnosis, 3) initial management, including family psychoeducation, 4) treatment, 5) ongoing management, and 6) follow-up.
Treatment and Prevention
There is no longer any doubt that children and adolescents can experience severe
depression. The questions that drive current research studies are how best to
intervene early to prevent the later onset of depression. Estimates from national
epidemiological studies of adults with psychiatric disorders indicate that many
adult mental disorders begin in childhood. The implications of these findings
are that early recognition and treatment of childhood psychiatric problems may
prevent later illnesses and their unfortunate consequences. Recognizing and
treating psychiatric illnesses early in life-particularly the devastating disorders
of depression and anxiety-may have a profound and long lasting effect on later
development, as recognition and treatment can help to avert the potentially
debilitating consequences of adult disorders.
Treatments
Considerable progress has been made in the past ten years documenting effective
treatments for young persons with depression. Most of the efforts to date have
focused on adolescents. More than a dozen clinical trials have demonstrated
that both cognitive-behavioral therapies (CBT) and interpersonal therapies (IPT)
are effective therapies for adolescents with depression. These treatments are
being delivered and examined in New York State. Studies have also documented
that nonspecific supportive psychotherapy, on the other hand, is not effective
in reducing depression. Delivered by trained professionals, CBT and IPT are
structured clinical interventions, that target specific factors associated with
depressive thinking or behaviors. For example, active problem solving, social
skills development, activity scheduling, and self-monitoring are often targeted
and taught in these structured treatments. Nonspecific supportive psychotherapies,
on the other hand, are unstructured "talking" therapies, often characterized
by supportive listening, play or other nondirective activities primarily designed
to provide emotional "support" to the individual.
For pre-pubertal children with depression, no long-term studies have been conducted to identify the most effective therapy. Similarly, there are no controlled trials of treatments for preschool depression, even though it has been found to exist in this population of children. Studies are needed to address these questions.
The use of pharmacologic treatments for children and adolescents has been studied with increasing rigor in recent years. It is clear that, unlike adults with acute depression, the older antidepressants (e.g., tricyclic antidepressants) do not work well for childhood depression. Newer antidepressant medications (e.g., SSRIs [selective serotonin re-uptake inhibitors]) have been examined over the past ten to 15 years and increases in their use have also been documented.12 In addition to psychiatrists, many nonpsychiatric physicians (primary care physicians) have been prescribing these medications for depressed adolescents. A national study examining rates of antidepressant use and suicide by geographic regions documented that as use of antidepressants for depression increased, there was a concomitant decrease in the number of teen suicide deaths.13
Recently the results of a major clinical trial on treatment of adolescent depression were released.14 In this ten-site clinical trial of adolescents with moderate to severe depression, which compared SSRIs, psychosocial treatments, their combination and placebo, short-term outcomes (at 12 weeks) demonstrated reductions in depressive symptoms associated with the use of SSRIs. Longer-term outcomes have not yet been published.
Concerns have recently emerged about both the safety and effectiveness of antidepressant medications with children and adolescents. On October 15, 2004, the Food and Drug Administration (FDA) announced that it was requiring a "black box" warning to the health professional labeling of all antidepressant medications regarding their use with children and adolescents.
After considering the large amount of information and controversy generated
by this issue, OMH summarized the data in a clinical advisory as follows:
- Currently, fluoxetine (Prozac) is the only antidepressant "labeled," that is approved by the FDA for use in pediatric depression (i.e., children and adolescents). The prescribing of all other antidepressants in children and adolescents for any use is categorized as "off-label" use.
- To date, only fluoxetine (Prozac)
has been shown to be clinically effective with adolescents who are depressed.
- An FDA review of 24 SSRI antidepressant
studies involving 4,400 children and adolescents concluded that all the SSRIs
(including fluoxetine) and other newer antidepressants could increase the
risk of suicide-related thoughts and/or self-harming behavior in some children
and adolescents. The FDA analysis identified the average medication-induced
risk to be 4% compared to 2% for a placebo. This means that statistically,
four children and adolescents out of 100 treated might show increased suicidality
due to the antidepressant medication. The medication-induced risk is greater
when starting or adjusting the dose of these antidepressant medications.
- In the 24 studies reviewed
involving children and adolescents taking SSRI antidepressant medications,
there were no deaths. Also, none of those with increased suicidal ideation
or behavior went on to commit suicide.
- New research in the treatment
of adolescent depression (i.e., the Treatment of Adolescents with Depression
Study) demonstrates that the combination of CBT therapy and antidepressant
medication (fluoxetine) results in successful treatment (71% of adolescents
who were depressed responded positively to the combination treatment compared
to 35% taking a placebo).
- In spite of the "black box" warning, the FDA has not taken a position that SSRIs and other new antidepressants are contraindicated in children and adolescents. Therefore, six medications (citalopram [Celexa], escitalopram [Lexapro], fluoxetine [Prozac], fluvoxamine [Luvox], paroxetine [Paxil], and sertraline [Zoloft]; three others, including bupropion (Wellbutrin), mirtazapine (Remeron), and venlafaxine (Effexor); and MAO inhibitors and tricyclic antidepressants can continue to be prescribed for children and adolescents if rational prescribing principles are followed.
The full text of this advisory can be found in Appendix 6 and on the OMH Web site (http://www.omh.state.ny.us/omhweb/advisories/programltr.htm). It includes a series of recommendations to assist practitioners, clinicians, and ultimately parents or guardians in making sound decisions. These recommendations are consistent with OMH's continued support for the use of evidence based treatments for children and adolescents with serious emotional disturbance.
Prevention
Research on the prevention of child and adolescent depression has focused on
treatment of maternal depression as a major risk factor for childhood depression
and on the development of school-based programs specifically aimed at reducing
the risk for depression. Interventions that target maternal depression have
found changes in cognitive development and behavioral problems among children;
longer-term studies are still needed to determine the direct effects on children,
although early results are promising.15 School-based prevention programs
for youth at risk of developing depression have demonstrated successful outcomes
in preventing the onset of full-blown depression.16
Because anxiety often precedes
depression, especially among girls, and because effective CBT and pharmacological
treatments for anxiety disorders exist, there is a strong possibility that treatment
of anxiety problems in children or adolescents, including trauma-related symptoms,
may prevent the development of depression.
Finally, there is emerging support for the value of psychoeducational family
programs for families of children with a range of psychiatric problems, including
depression. These educational programs-often co-taught by parents and professionals-are
designed to increase awareness and knowledge about effective identification,
early intervention, and treatment for children and adolescents with or at risk
of depression. Family members are taught to identify the symptoms and to recognize
early warning signs that may suggest a predisposition to anxiety or depression.
They are also taught how to access information about mood disorders, and are
provided with information about stress reduction, medication, and medication
side effects. The effects of various stressors in a child's life are also examined
in the context of the child's major environments such as school, home, and community.
Participants are able to network with other parents to discuss common issues
such as early identification, parenting strategies, and working with the school
system.
Lack of Treatment and
Its Consequences
Untreated, the consequences of major depression in children and adolescents
can be devastating for both the child and for his/her family. While the most
serious consequence of untreated depression may be suicide, there are other
serious developmental, personal, and social consequences that may result. These
consequences can affect relationships with family members, peers, school success,
work productivity, and adult development. Clearly recognition, identification,
and treatment of depression in children and adolescents can have profound effects
on the life course.
Approximately 90% of teenagers who die by suicide suffer from a treatable mental illness. For more than a decade, Columbia University has worked to perfect a reliable and easy screening program for suicide risk and other mental disorders. The resulting program, TeenScreen®, has been implemented in 41 states nationwide. The TeenScreen® Program offers evidence-based adolescent suicide and mental health screening programs to government and mental health agencies, non-profit organizations, schools, physicians, and drop-in clinics. At this time, consultation, training and implementation assistance are offered free of charge. More information about the TeenScreen® Program is available on the Web at http://www.teenscreen.org/.
Future Directions
OMH is committed to providing a comprehensive range of services for children
and adolescents experiencing mood disorders, as well as support for their families
and caretakers. To launch an effective strategy to prevent the onset, recurrence,
or sequelae of mood disorders, we will implement a set of strategies with targeted
dissemination objectives, which will improve the identification, treatment,
and prevention of child and adolescent depression.
OMH will focus its efforts on promoting a statewide response by targeting the following activities:
- A public awareness campaign
to improve recognition of the early indicators for mental disorders in children
- Promotion of suicide awareness,
screening, and referral/treatment services in schools and communities to identify
children and adolescents at risk
- Tools and training for front-line
clinical staff in hospital and outpatient clinic systems to improve recognition
of trauma, anxiety, and depression among children and adolescents and to improve
delivery of effective, evidence-based psychosocial and pharmacologic treatments
for affected youth
- Dissemination of the Guidelines
for Treatment of Adolescent Depression (referenced earlier in this chapter)
to primary care providers statewide
- Promotion of family psychoeducation
and support services to assist families in recognizing early indicators of
psychiatric problems, to encourage seeking evidence-based services, and to
promote supportive services family to family
- Implementation of tracking
and monitoring systems including specific measurable and timely outcomes;
use of Standardized assessment tools for diagnosing and tracking outcomes
- Encouragement to programs and clinics implementing the monitoring of these programs to work as collaborative learning partners
In June 2005 OMH and the State
Offices of Alcoholism and Substance Abuse Services (OASAS), and Children and
Family Services (OCFS), will be co-sponsoring the Children's Research to Practice
Symposium. The symposium will include interdisciplinary sharing of the latest
findings in neuropsychiatry, major treatment trials and services research in
children's mental health. Additional information about the symposium is available
on the OMH Web site at:
http://www.omh.state.ny.us/omhweb/child_symposium/.
Additional information about children and depression research is included in
Appendix 7.
Notes
1 Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman
S et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric
disorders in the United States. Results from the National Comorbidity Survey.
Archives of General Psychiatry, 51:8-19
2 Goodwin FK, & Jamison KR. (1990). Manic-depressive illness.
New York: Oxford University Press.
3 Guze, S. B., & Robins, E. (1970). Suicide and affective
disorders. British Journal of Psychiatry, 117, 437-438.
4 Murray CJL, Lopez AD, eds. (1996). The global burden of disease
and injury series, volume 1: A comprehensive assessment of mortality and disability
from diseases, injuries, and risk factors in 1990 and projected to 2020.
Cambridge, MA: Published by the Harvard School of Public Health on behalf of
the World Health Organization and the World Bank, Harvard University Press.
5 Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab-Stone
ME, Lahey BB, Bourdon K, Jensen PS, Bird HR, Canino G, & Regier DA. (1996).
The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3):
Description, acceptability, prevalence rates, and performance in the MECA study.
Journal of the American Academy of Child and Adolescent Psychiatry, 35(7), 865-877.
6 Angold A, Costello EJ, Farmer EMZ, et al. (1999) Impaired but
undiagnosed. Journal of the American Academy of Child and Adolescent Psychiatry,
38, 129-137.
7 National Institute of Mental Health. (2000).Depression in children
and adolescents: A fact sheet for physicians. Bethesda, MD: Department
of Health and Human Services.
8 National Center for Injury and Prevention Control. Suicide:
Fact sheet. Accessed online January 12, 2004, at http://www.cdc.gov/ncipc/factsheets/suifacts.htm
9 Office of the Surgeon General. (1999). The Surgeon General's
call to action to prevent suicide. Washington, DC: Department of Health
and Human Services.
10 Weissman MM, Wickramaratne P, Nomura Y, Warner V, Verdeli H, Pilowsky
DJ, Grillon C, & Bruder G. (2005). Families at high and low Risk for
depression: A 3-generation study. Archives of General Psychiatry, 62, 29-36.
11 Cheung A, Zuckerbrot R, Jensen P, Levitt A. (2004, October). North
American guidelines for the management of adolescent depression in primary care.
Presented at the annual meeting of the Canadian Academy of Child and Adolescent
Psychiatry, Montreal.
12 Zito JM, Safer DJ, dosReis S, Gardner JF, Soeken K, Boles M, &
Lynch F.(2002). Rising prevalence of antidepressants among U.S. youths.
Pediatrics, 109(5), 721-727.
13 Olfson M, Shaffer D, Marcus SC, & Greenberg T. (2003). Relationship
between antidepressant medication treatment and suicide in adolescents.
Archives of General Psychiatry, 60, 978-982.
14 March J, Silva S, Petrycki S, Curry J, et al. (2004). Fluoxetine,
cognitive-behavioral therapy, and their combination for adolescents with depression:
Treatment for Adolescents with Depression Study (TADS) randomized controlled
trial. Journal of the American Medical Association, 292, 807-820.
15 Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I, Jackson-Triche
M, & Wells KB. (2003). Improving care for minorities: Can quality improvement
interventions improve care and outcomes for depressed minorities? Results of
a randomized, controlled trial. Health Services Research, 38(2), 613-630.
16 Clarke GN,
Hornbrook M, Lynch F, Polen M, Gale J, Beardslee W, et al. (2001). A randomized
trial of a group cognitive intervention for preventing depression in adolescent
offspring of depressed parents. Archives of General Psychiatry, 58, 1127-1134.