Major depressive disorder in adolescence: a brief review of the recent treatment literature

The Longitudinal Impact of Maternal Depression and Neighborhood Social Context on Adolescent Mental Health

Purpose

Maternal depression and neighborhood characteristics are known to be associated both with each other and with adolescent mental health outcomes. These exposures are also subject to change throughout the life of a child. This study sought to identify multi-trajectories of maternal depression (MD) and self-reported neighborhood collective efficacy (NCE) over a 12-year period and determine whether these trajectories are differentially associated with adolescent mental health.

Methods

Data from the Fragile Families and Child Wellbeing study, a longitudinal cohort study of new parents and their children, were used. Maternal depression (MD) and self-reported NCE when the child was 3, 5, 9, and 15 years of age were the primary exposures of interest. Adolescent depression and anxiety symptomology when the child was 15 years of age were the primary outcomes. Primary analyses were conducted using multi-trajectory modeling and linear regressions.

Results

Five multi-trajectories were identified, two of which were characterized by no MD but either high or low NCE, and three of which were characterized by similarly moderate levels of NCE but either increasing, decreasing, or consistently high MD. Children of mothers with increasing or consistently high depressive symptomology and moderate NCE had significantly higher depression and anxiety scores compared to children of mothers with no depressive symptomology and high NCE.

Conclusion

Adolescents with consistent and proximal exposure to MD are most likely to suffer from adverse mental health and should be provided with appropriate support systems to mitigate these outcomes.

Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines

ABSTRACT

There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.

Magnetic seizure therapy in an adolescent with refractory bipolar depression: a case report

Magnetic seizure therapy (MST) has shown efficacy in adult patients with treatment-resistant depression with limited impairment in memory. To date, the use of MST in adolescent depression has not been reported. Here we describe the first successful use of MST in the treatment of an adolescent patient with refractory bipolar depression. This patient received MST in an ongoing open-label study for treatment-resistant major depression. Treatments employed a twin-coil MST apparatus, with the center of each coil placed over the frontal cortex (ie, each coil centered over F3 and F4). MST was applied at 100 Hz and 100% machine output at progressively increasing train durations. Depressive symptoms were assessed using the 24-item Hamilton Depression Rating Scale and cognitive function was assessed with a comprehensive neuropsychological battery. This adolescent patient achieved full remission of clinical symptoms after an acute course of 18 MST treatments and had no apparent cognitive decline, other than some autobiographical memory impairment that may or may not be related to the MST treatment. This case report suggests that MST may be a safe and well tolerated intervention for adolescents with treatment-resistant bipolar depression. Pilot studies to further evaluate the effectiveness and safety of MST in adolescents warrant consideration.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: Depression in End-Stage Renal Disease Patients Treated With Hemodialysis: Tools, Correlates, Outcomes, and Needs

Depression has been thought to be the most common psychiatric abnormality in hemodialysis (HD) patients. There are few data using psychiatric diagnostic criteria and a lack of large, well-designed epidemiologic research studies in patients with end-stage renal disease (ESRD) that can render definitive results on this topic. The prevalence of major depression or a defined psychiatric illness in ESRD patients is unknown, but is probably between 5% and 10%. The prevalence of increased levels of depressive affect is greater. Estimates of the prevalence will vary according to the screening techniques used. Depression could affect medical outcomes in ESRD patients through several mechanisms. Correlational analyses suggest stressors and protective factors play roles in mediating the level of depressive affect and associated outcomes. Although early studies suggested a deleterious effect of depression on survival in ESRD patients, more recent studies had failed to confirm such findings. The use of longitudinal analyses and larger samples has confirmed an association of depressive affect and morbidity and mortality in more contemporary ESRD populations. The importance of depressive affect compared with the presence of a defined psychiatric syndrome in mediating clinically important outcomes in patients with chronic kidney disease has not been determined. Studies of interventions designed to reduce levels of depressive affect in ESRD patients are urgently needed.

Adolescent mental health literacy: Young people's knowledge of depression and help seeking

This study examined the mental health literacy of a group of adolescents, with particular reference to their ability to recognize symptoms of depression in their peers. Respondents were 202 Australian adolescents (122 males, 80 females) aged 15-17 years. Their mental health literacy was examined through a questionnaire that presented them with five scenarios of young people. Respondents showed a mixed ability to correctly recognize and label depression, although they were able to differentiate depressed and non-depressed scenarios in terms of severity and expected recovery time. Results are discussed in light of findings from adult mental health literacy and clinical implications.

Substance use and depression. Comparative course in adolescents

OBJECTIVE

To examine the relation between depression and substance use in adolescents and the concomitant courses of both disorders.

METHODS

Four individual interviews were administered to 85 adolescent substance users aged 14-19 years (mean 17.1 years, SD 1.4) over a 3.5 year period using the Adolescent Drug Abuse Interview (ADAD) and the Beck Depression Inventory (BDI-13).

RESULTS

No predictive effect was observed on one dimension over the other, but each dimension was predictive of its own course. A decrease in substance-use severity paralleled a decrease in depressive state. Similarly, stable substance-use rates, either at a low or a high level, tended to be associated with low or high levels of depression, respectively. However, an increase in substance use was not accompanied by an increase in depressive states. Moreover, depression varied greatly between adolescents, and according to gender and age.

CONCLUSIONS

Depressive states and substance use in adolescents can vary considerably overtime, and are closely but rather synchronically related. Since most of the adolescents do not seek help for substance-related problems, substance use should be systematically assessed in adolescents presenting with a depressive state.

[Selective serotonin reuptake inhibitors in major depressive disorder in children and adolescents (ratio of benefits/risks)]

Major depressive disorder in children and adolescents is associated with high risk of suicide and persistent functional impairment. While psychological treatments are used as a first line treatment in mild and moderately severe depression in this age group, the number of prescriptions for antidepressant medication (SSRI) has grown in recent years. Recently, FDA and MHRA advised that most of SSRI should not be used to treat MDD under the age of 18 years. They may increase the risk of suicidal thoughts and self harm. We reviewed the recent literature on efficacy and suicide risks of SSRI in depressed young people. Conflicting findings of SSRI efficacy have been reported in clinical studies. The discrepancies could be related to the heterogeneous samples and the absence of a standard definition of treatment effectiveness. In randomised placebo-controlled antidepressant clinical trials (RCT), the assessment of treatment effectiveness is commonly made with the CDRS-R (improvement of 20% or 30% or 40%) and CGI. SSRI demonstrated significantly, but modest, improvement compared with placebo in CGI score of 1 or 2: 10% more for sertraline, 16.8% more for paroxetine and between 16 to 24% more for fluoxetine. In adults, RCT studies have shown placebo response rates of 30% to 50%, drug response rates of 45% to 50% and drug-placebo differences of 18% to 25%. The highest placebo response rates, in young people, may be related to the highly selected group not representative of the general population of depressed patients and/or to the high youths' sensibility of psychotherapy. Patients participating in antidepressant clinical trials have a low BDI and CDI in Emslie's study for example (2002). In adults, previous reports suggest that SSRI use is associated with increased suicidal risk. But the analyse of 48 277 depressed patients participating in RCT for nine FDA approved antidepressants fail to support an overall difference in suicide risk between antidepressants (SSRI) and placebo treated subjects. An inverse relationship between regional change in use of antidepressants (increased) and suicide (decreased) is found in young -people in United States from 1990 and 2000. We can not draw a conclusion from few studies with few -participants. None suicide have been reported in pharmacological studies. And the link between "suicidality" and MDD can not be excluded. The instruments of assessment in depressed young patients are based on extensions of adult procedures. Whereas clinical picture of MDD in children, adolescents and adults have some differences. Depressed youngsters have more pronounced mood lability. Depressed adolescents have more anhedonia than depressed children. Future investigations into the efficacy and safety of treatments for children and adolescents depression should use specific instruments directly built on phenomenological and clinical picture of depressed children and adolescents. Comparison studies of pharmacotherapy, specific psychotherapies (not only CBT) and combined therapies are necessary to identify the adolescents who will benefit the most from specific or combined therapies. Further studies into the factors that influence treatment outcome including clinical picture (clinical dimensions, severity, duration, co morbidity), genetic factor, age, and i-llness course may help identify appropriate treatments for children and adolescents with MDD. Studies should include patients more severely ill, with associated psychiatric troubles, treatment resistance, history of relapses... In clinical studies, the link between "suicidality" and some clinical dimensions (which take part in clinical picture or not) must be analysed by assessing anhedonia, hopelessness feel, impulsive trait, borderline personality, familial inter-action, biological indices. New treatment should be expand and their efficacy and safety must be study: St John's worth, Bright light therapy, Trans-cranial Magnetic Stimulation.

IN PRACTICE

suicide and MDD have a strongest relation and it must be investigate syste-matically during the course of MDD. The suicide risk increases in the context of past history of suicide attempts, hopelessness, psychosis, impulsivity traits, substance abuse, familial dysfunction, life events, open access of arms. The use of SSRI in depressed children and adolescents is also the question of the quality and the support of the consultant and the mode of the prescription.

Selective serotonin reuptake inhibitors for children and adolescents with major depression: current controversies and recommendations

Recent warnings about potential serious adverse effects with the selective serotonin reuptake inhibitors in children and adolescents with depression raises questions about the risk-benefit ratio of these drugs in this population. Published safety and efficacy trials of SSRIs for the treatment of youth with depression are critically reviewed. These data were augmented by information from regulatory hearings in 2003-2004 and selected open-label reports. Based on this review, recommendations for medication treatment and monitoring of children and adolescents with major depression on SSRIs are provided. Emerging data from several clinical trials show that the SSRIs provide moderate benefits for youth with depression. In addition, SSRI treatment may be associated with increased risk of behavioral activation, self-harm, and suicidal ideation. Appropriate use of the SSRIs in children and adolescents requires careful diagnostic assessment, evaluation of comorbidity, and close monitoring, especially early in treatment.

A review of the growing evidence base for pediatric psychopharmacology

This article provides an update of pediatric psychopharmacologic treatment evidence and focuses on six classes of medications in pediatric populations: psychostimulants, mood stabilizers, SSRIs, tricyclic antidepressants, antipsychotic agents, and other agents. The evidence is organized by disorder so that it is most useful to practicing clinicians. We begin each section with a brief introduction and summary of the findings published before January 1998. Priority is given to clinical trials that use random assignment and use of a comparison group (ie, placebo-control, head-to-head comparison, or cross-over design). Serious concerns remain about the efficacy and safety of many of these agents for use in children and adolescents. While a great progress is being made, there is clearly much work left to be done.