Adolescent depression: Diagnostic skills can differentiate teen angst from psychopathology
Depression in teenagers is persistent and characterized by high rates of comorbid psychiatric conditions. Based on clinical evidence, the following strategies can help you determine appropriate treatment.
Adolescents with depressive disorders tend to arrive in psychiatrists’ offices when their behavior has already been identified as problematic. Suicide attempts, academic failure, substance abuse, and family conflicts can all lead to teen psychiatric referrals. Other times, subtler changes in behavior may lead a family doctor or pediatrician to suspect depression and to send an adolescent to you for a psychiatric consultation.
The psychiatrist’s task is challenging. Adolescents are usually brought in by their worried parents and may not want to talk to a psychiatrist. Or they may be unable to accurately describe their internal states. Even people who know an adolescent well may not discern the emotions that drive his or her behavior. Adding to the mix are the recurrent nature of major depression in adolescents and the likelihood of complicating comorbid psychiatric conditions (Box). 1-6
Based on clinical evidence, we offer advice to help you promptly identify and effectively treat adolescents with depressive disorders. We also provide preliminary information on two studies examining medication treatment, psychotherapy, and combined treatment for teens with major depression.
Adolescent depression disorders
Symptoms of depression in adolescents are similar to those in adults, and it is appropriate for psychiatrists to use DSM-IV diagnostic criteria for making the diagnosis. The three primary depressive disorders for both adults and adolescents are major depressive disorder (MDD), dysthymic disorder, and depressive disorder not otherwise specified (NOS).
ADOLESCENT DEPRESSION: PORTRAIT OF A PERSISTENT DISORDER
Depression is relatively rare among children but becomes common after the onset of puberty. In particular, recurrent depression often starts in adolescence. Here are the statistics:
- Up to 9% of adolescents meet diagnostic criteria for major depressive disorder (MDD), and up to 25% suffer from it by their late teens.
- MDD affects boys and girls equally in childhood, but the prevalence seems to increase in girls after puberty.1,2
- Depression in adolescents is characterized by high rates of comorbid psychiatric conditions. In general, the younger the age of onset, the higher the rate of comorbid conduct disorder, attention-deficit/hyperactivity disorder, and/or anxiety disorder. 3
- Adolescent depression tends to persist. An estimated 45 to 70% of children and adolescents with MDD have recurrent episodes.4 At particularly high risk for recurrence are adolescent girls with depression, adolescents with multiple MDD episodes, and adolescents with a family history of recurrent depression.
- As many as 50% of teens with MDD attempt suicide within 15 years of their initial episode, and more than 20% make recurrent attempts.4,5 No good estimates of the rate of completed suicide are available. One 15-year follow-up of a sample of depressed adolescents reported a suicide rate of 7.7%.5 Boys are much more likely to complete suicide than girls across all racial groups.6
Although the symptoms that make up the diagnostic criteria are similar for adults and teens, the behavioral manifestations and response to treatment may differ. The adolescent may present as irritable and angry, rather than overly sad. Impairments in functioning are likely to be related to decline in school performance, social withdrawal, or increased conflicts with peers and family.
As for treatment, certain antidepressant medications of proven efficacy in adults (i.e., tricyclics) do not seem to work for adolescents.
MDD is a time-limited episode of depressive symptoms severe enough to cause functional impairment, such as decline in school performance, social withdrawal, or increased conflicts with peers and family. Symptoms must be present at least 2 weeks.
Dysthymia is a chronic depression that is less severe than MDD and lasts 1 year or longer without sustained remission. It often begins early in childhood and may include periods of increased symptoms consistent with major depression (sometimes called “double depression”).
Depressive disorder NOS is a category of depression that, though clinically significant, does not meet the full criteria for severity, duration, or level of impairment of MDD or dysthymia.
Unless otherwise specified, the terms “depression” and “depressive disorder” in this article are used generically to include all three of these disorders.
Depressive disorders must be differentiated from bipolar disorder, which is characterized by least one prior episode of mania (for bipolar type I) or hypomania (for bipolar type II). The clinical picture of bipolar disorder in youths may differ from that seen in adults. For example, bipolar youth often present with dysphoric mood interspersed with frequent, short periods of intense emotional lability and irritability, rather than “classic” euphoria.
To diagnose a depressive disorder in an adolescent, information is typically obtained from multiple sources, most commonly the teenage patient and at least one of the parents. Because several sources are involved, however, the information may be conflicting. For instance, the adolescent may contradict a parent’s report that he or she is having difficulties in school or has a substance abuse problem.
Interviewing skills and clinical judgment are required of the clinician in these situations. It is important to:
- obtain a complete description of the adolescent’s behavior and mood over time and as accurate a description as possible of when changes occurred
- assess comorbid conditions (particularly anxiety, attention-deficit/hyperactivity disorder [ADHD], conduct disorder, and substance abuse)
- differentiate between unipolar MDD and bipolar disorder
- evaluate the risk of suicide.
DEPRESSION IN ADOLESCENTS AND ADULTS
Same types of diagnostic categories (i.e., major depression, dysthymia, depression NOS)
To diagnose dysthymia, minimum duration of mood disturbance must be 1 year in adolescents (2 years in adults)
Same diagnostic symptoms criteria
Mood is often irritable in adolescents (rather than depressed)
More common in females
Suicide is more common among males
Evidence of efficacy of SSRI antidepressants
No evidence of efficacy of tricyclic antidepressants in adolescent depression
Interviewing Standardized diagnostic interviews, such as the Schedule for Affective Disorders and Schizophrenia for children (K-SADS), are commonly used to research adolescent depression but require special training and approximately 1 to 2 hours to administer. As an alternative, clinicians generally develop their own “semi-structured interview” to try to collect all the relevant information required for an accurate diagnosis.7
The interview should be conducted with the adolescent and the parent(s), first separately for ease of disclosure then together to reconcile any differences in the information they report. Open-ended questions and time for building rapport may facilitate disclosure from a reticent adolescent. At times, however, one must make the diagnosis by relying more on reports from others who know the child well. Building a trusting therapeutic relationship then becomes part of ongoing treatment.
Standardized measures In addition to the interview, standardized self-report and other-report measures can help:
- The Child Depression Rating Scale-Revised, commonly used in clinical research, can also be used in practice to quantify symptom severity and document treatment response. A score above 40 usually indicates major depression; a score below 28 indicates remission of depression.8-10
- The Beck Depression Inventory (BDI), a 21-item self-report questionnaire for adults, has reasonable reliability and validity for adolescents. Its modest specificity suggests that it may measure general distress and dysphoria, which is not specific to depressive disorders. The language may be too difficult for some younger adolescents and those with poor reading comprehension skills.
- The Children’s Depression Inventory, a version of the BDI for prepubertal children, can be considered for adolescents whose cognitive and/or reading skills are less mature.
- Achenbach’s Child Behavior Checklists and other standardized questionnaires can screen for comorbid psychopathology.
Assessing psychosocial stress, such as conflicts with parents or peers, school problems, or risk-taking behavior, is also important. Depressed youth often have family members with histories of depression, alcoholism, anxiety, and other psychiatric diagnoses. History of sexual abuse has been linked to depression.3 The depressed adolescent’s impaired functioning in school and at home may cause secondary stress, increasing the burden of illness and need for treatment.
Suicide risk Although suicide remains rare among adolescents in general, the rate of suicide among this age group has risen dramatically over the past decade, particularly among younger teens and preteens. In 1997, suicide was the third leading cause of death in adolescents after accidental injuries and homicide.
Adolescents with depressive disorders are at increased risk for suicide, and boys are more likely than girls to attempt and complete suicide. It is therefore imperative to assess and document suicide risk for each adolescent who presents with depressive symptoms.
After establishing a rapport, the most effective screening is a straightforward conversation with the adolescent about suicidal ideation, intent, and behavior. Assess the social context of support and psychopathology in the family, availability and accessibility of lethal suicide methods (e.g., firearms in the home), and presence of events that could influence imitative suicidal behavior (e.g., a friend’s suicide).6
Approaches to adolescent depression include (in increasing order of intensity and complexity) watchful monitoring, nonspecific supportive therapy, pharmacotherapy, specific psychotherapy (i.e., cognitive-behavioral or interpersonal therapy), and combined treatment (e.g., psychotherapy plus pharmacotherapy, adolescent psychotherapy plus family therapy).
There are no clear-cut guidelines as to whether pharmacologic or psychosocial therapy should be offered first.11 In the community, patient and family preferences, past treatment response, and the clinician’s background and expertise influence the choice of treatment. As with adults, adolescents deemed at high risk for suicidal behavior must receive immediate attention from mental health professionals and must be monitored, usually in an inpatient setting.
Watchful monitoring means to wait and see if the youth improves spontaneously.
In some studies, nearly one-half (48%) of adolescents with depression were found to go into spontaneous remission within 8 weeks.12 Watchful monitoring, however, would leave most patients still depressed, and no predictors of spontaneous remission have been identified.
SSRI DOSAGES FOUND TO BE EFFECTIVE IN ADOLESCENTS WITH MDD
Dosage (per day)
Wagner et al, 200110
Keller et al, 200114
Donnelly et al, 200115
Because of the risks of suicide and social and academic impairment, monitoring alone is acceptable only for a few weeks, and only in cases where depression is mild and uncomplicated. In any case, “monitoring” requires that you periodically reassess the teen and be available for consultation between assessments.
Nonspecific supportive therapy Most psychotherapy provided in the community probably is nonspecific (i.e., not theoretically driven or conducted according to a treatment manual) and supportive (i.e., aimed at providing encouragement). This approach is known to be less effective than specific psychotherapies or antidepressant pharmacotherapy, but we have virtually no data comparing it with lack of treatment.
Nonspecific supportive therapy can be considered a reasonable first-step treatment for depressed teens without complicating risk factors.13 Specific treatment is indicated, however, if the adolescent does not improve in a few weeks.
Pharmacotherapy A few placebo-controlled clinical trials have studied the efficacy of selective serotonin reuptake inhibitors (SSRIs) in outpatient adolescents with major depression. It must be noted that practically all the available data relate to major depression, and no systematic studies have been done in dysthymia and other types of depression in this population.
The SSRIs fluoxetine,8,9 citalopram,10 paroxetine,14 and sertraline 15 can decrease symptoms of adolescent depression over 2 to 3 months when given at dosages similar to those used in adults (Table 2). At this time, there are no data that suggest the SSRI dosage must be different in younger (12-year-old) compared with older (18-year-old) adolescents, or in girls compared with boys.
The response rate (adolescents who were substantially improved at end of treatment) ranged from 52 to 65% with SSRI medication and 33 to 48% with a placebo. This means that one would need to treat about six adolescents in order to add one to those who would improve by taking a placebo. Thus, 6 is the number needed to treat (NNT), a common index used to make decisions in evidence-based medicine. As a comparison, the NNT is 1.5 for stimulant treatment of ADHD, indicating that stimulants are more effective in ADHD (i.e., the difference between an active drug and a placebo is greater) than SSRIs are in depression.
It must be noted that receiving a placebo in clinical trials of depression does not equal absence of treatment. Typically, research participants assigned to a placebo have weekly clinical contacts, so placebo treatment could be defined as “nonspecific clinical management.” In any case, the NNT for SSRIs in adolescent depression does not appear to be substantially different from that found in adults.