Sub-syndromal depression in adolescents attending primary care: frequency, clinical features and 6 months outcome

Protocol for a nested case-control study: identifying neuroimaging biomarkers for the progression of subclinical depression and qi-stagnation constitution to major depressive disorder in adolescents

Background

Major depressive disorder (MDD) frequently results in suboptimal treatment outcomes and elevated recurrence rate, with patients frequently engaging in self-harm and suicidal behavior, thereby placing a heavy burden on families and society. Specifically, MDD in adolescents is linked to an elevated suicide risk. Thus, early identification and intervention is crucial for adolescents at high risk for developing MDD. Subclinical depression (SD), characterized by depressive symptoms that do not meet the full criteria for MDD, substantially increases the risk of developing MDD. According to Traditional Chinese Medicine body constitution theory, Qi-stagnation constitution (QSC) is also considered a significant risk factor for the progression to MDD. This study protocol aims to identify neuroimaging biomarkers for the progression from adolescents with SD and QSC to those with MDD, facilitating early intervention strategies.

Methods and analysis

This nested case-control study includes both longitudinal follow-up and cross-sectional comparison. Three hundred first-year senior high school students diagnosed with SD and QSC will be recruited. The 300 adolescents will undergo rs-fMRI scans at baseline and again after one year. We then divide the 300 adolescents with SD and QSC into two groups based on whether they progress to MDD after one year. Functional brain networks will be constructed based on 400 regions of interest (ROIs). Neuroimaging measures, including regional homogeneity and low-frequency fluctuation for each ROI, as well as graph-based global efficiency, nodal efficiency, and nodal centrality from the binary networks, will then be calculated. Finally, differences in these neuroimaging measures between the two groups at baseline will be analyzed to identify biomarkers that can predict the progression from adolescents with SD and QSC to those with MDD.

Study registration

This study protocol does not involve clinical interventions and is classified as an observational study, so it was not subject to prior registration.

Subthreshold depression - concept, operationalisation and epidemiological data. A scoping review

PURPOSE

In diagnostic systems (e.g., DSM-5, ICD-10), depression is defined categorically. However, the concept of subthreshold depression (SD) has gained increasing interest in recent years. The purpose of the present paper was to review, based on a scoping review, the relevant papers in this field published between October 2011 and September 2020.

MATERIALS AND METHODS

Of the 1,160 papers identified, 64 records could be included in further analysis. The scoping review was conducted using both electronic and manual methods.

RESULTS

The main result of the analysis is that the operationalisation criteria used are highly heterogeneous, which also leads to very heterogenous epidemiological data.

CONCLUSIONS

Clear conclusions are not possible scrutinising the reported results. Most definitions seem to be arbitrary, with considerable overlap (e.g., between SD and minor depression). The review also revealed that the impact of SD on quality of life and related parameters appear to be in the range of the respective impact of major depression (MD) and therapeutic approaches might be helpful for SD and also for the prevention of conversion from SD to MD. Keeping the presented difficulties in mind, a proposal for the definition of SD is made in the present paper in order to facilitate the discussion leading to more homogeneous criteria.

[Behavioral phenomena of depression in adolescence]

OBJECTIVE

To study behavioral phenomena of depressive disorders in adolescence.

MATERIAL AND METHODS

Ninety-five patients, aged 12 to 17 years, with a mixed disorder of emotions and behavior without cognitive impairment and psychotic disorders were examined. Clinical-psychopathological, clinical-follow-up methods, Beck scales, the Spielberger-Khanin scale, Zung and PDO questionnaires, statistical analysis were used.

RESULTS

The structure of this syndrome included affective disorders: low mood (n=84 88.4%), loss of interest in studies, everyday life (n=81, 85.3%) and behavioral disorders: manifestation of aggression (n=47, 49.5%), auto-aggression (n=44, 46.3%), suicidal thoughts (n=34, 35.8%), decrease in academic performance (n=35, 36.8%), low motivation for learning, refusal to attend school (n=24, 25.3%). Clinical assessment of the characteristics of behavioral disorders demonstrated the heterogeneity of symptoms, which made it possible to distinguish two groups: psychopathic and anxious behavior. In group I, (n=47, 38.3%) predominated aggression, protest reactions (72.3%), (p<0.001), conflicts with teachers, classmates (87.2%), (p=0.014), addictions (25.5%), (p=0.011). In group II (n=48, 22.9%), there were anxiety symptoms (60.4%, p=0.00015), emotional lability, isolation, with a predominance of schizoid personality traits (62.5%) (χ2=.56, p=0.024, φ=0.242) and with a weak emancipation reaction (78.6%) (χ2=5.16, p=0.04, φ=0.233).

CONCLUSION

Behind the behavioral phenomena of depressive disorders, psychopathic and anxious symptom complexes can occur. These disorders determine the dynamic aspect of the formation of a depressive disorder and occur mainly at the onset of the syndrome. Only long-term follow-up of such patients can answer the question of which nosological form adolescent depression belongs to.

[Clinical and psychopatological features of endogenous depressions in young women]

OBJECTIVE

To study the features of psychopatological structure of endogenous depression in young women and to identify correlations between various clinical types of depression and their nosological affilation.

MATERIAL AND METHODS

The results of clinical/psychopathological examination of 107 female patients, aged 16 to 25 years, with endogenous depression with one of the following ICD-10 diagnosis: (F34.0; F31.3-F31.5; F21.3-F.21.4+F31.3-F31.5; F60.X+F31.3-F31.5) were analyzed.

RESULTS

Several types of endogenous depression were identified: 1) hysterical depression with hysterical-conversions, and also the phenomena of delusional fantasies; 2) dysmorphic depression with predominance of over-valued ideas of physical disability, self-inferiority and eating disorder; 3) depersonalization depression with depersonalization-derealization symptoms; 4) psychopath-like depression with exaggerated behavior, opposition and impulsivity; 5) existential depression with a feeling of losing the life meaning and often pessimistic worldview; 6) psychasthenic depression with the low self-esteem and exaggerated introspection combined with obsessive-phobic disorder; 7) anxious-melancholic depression with anxiety, melancholy and ideas of self-accusation and self-inferiority; 8) depression with symptoms of adolescent asthenic insolvency with difficulties of understanding information, increasing intellectual exhaustion. We revealed differences in motives for committing non-suicidal self-harm behavior and suicidal behavior in typological variants of depressions.

CONCLUSION

Hysteroform and psychopathic depressions prevail in personality disorders, while psychosthenic-like, anxious-melancholic and existential depressions are more frequent in affective disorders. Depersonalization depressions are more common in schizotypal disorder. When comparing the types of depressions in boys as reported in previous research with those in girls, the prevalence of hysteroform and anxious-melancholic variants in girls is revealed.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings.

METHODS

By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience.

RESULTS

Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan.

CONCLUSIONS

This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Service use in adolescents at risk of depression and self-harm: prospective longitudinal study

PURPOSE

Although depression and self-harm are common mental health problems in adolescents, there are barriers to accessing help. Using a community-based sample, this study investigates predictors of service contacts for adolescents at high risk of depression and self-harm.

METHODS

Three thousand seven hundred and forty-nine (3,749) 12- to 16-year-olds in UK secondary (high) schools provided baseline and 6 months' follow-up data on mood, self-harm and service contacts with a range of primary and secondary healthcare services.

RESULTS

Although most adolescents at high risk of depression or self-harm had seen their general practitioner (GP) in the previous 6 months, less than one-third had used primary or secondary healthcare services for emotional problems. 5 % of adolescents who reported self-harm had seen specialist child and adolescent mental health services in the previous 6 months. In longitudinal analyses, after adjustment for confounders, both depression and self-harm predicted the use of any healthcare services [adjusted odds ratio (AOR) = 1.34 (95 % CI 1.09, 1.64); AOR = 1.38 (95 % CI 1.02, 1.86), respectively] and of specialist mental health services [AOR = 5.48 (95 % CI 2.27, 13.25); AOR = 2.58 (95 % CI 1.11, 6.00), respectively]. Amongst those with probable depression, 79 % had seen their GP and 5 % specialist mental health services in the preceding year.

CONCLUSIONS

Most adolescents at high risk of depression or self-harm see their GP over a 6-month period although only a minority of them access specialist mental health services. Their consultations within primary care settings provide a potential opportunity for their identification and for signposting to appropriate specialist services.