adolescent depression: what we all should know
TRANSCRIPT
Adolescent DepressionWho is at risk and why?
11/16/2015
Kaja LeWinn, Sc.DAssistant Professor of Psychiatry
Adolescent Depression: Who is at risk and why? 2
What we are discussing today
Little “d” depression
‒ “That movie made me so depressed”; ‒ “I’m so depressed, they ran out of my favorite potato chips”
vs. Major Depressive Disorder (MDD)
‒ At least 2 weeks of depressed mood or losing interest in pleasurable activities
‒ Functional impairment in social, occupational, or educational settings
11/16/2015
05/02/2023Adolescent Depression: Who is at risk and why? 3
The Burden of Depression: DALYsDisability-Adjusted Life Years (DALYs): years lost to early death, disability, or poor health caused by the illness1
1World Health Organization (2012)http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html; Whiteford et al., 2010, Lancet
Worldwide, mental health disorders account for 7.4% of disease burden2
Adolescent Depression: Who is at risk and why? 4
DALYs for mental health disorders by age1
1Whiteford et al. 2010. The Lancet
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05/02/2023Adolescent Depression: Who is at risk and why? 5
Adolescent Depression in the U.S.
National Survey on Drug Use and Health, Mental Health Findings; SAMHSA 2013
Adolescent Depression: Who is at risk and why? 6
What makes adolescence unique?
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Presentation Title and/or Sub Brand Name Here7
Adolescence as a sensitive period of development
A developmental period marked by greater sensitivity to stimuli Adolescence is a sensitive period for the development of the social brain1,2
• Heightened sensitivity to social cues
• Heightened influence peers
• Important rewards and threats are in the social domain; high sensitivity to social rejection
Adolescence is a time of great learning, adaptation, and motivation But also a time of vulnerability 1Dahl et al., 2012, Nature Neuro Rev; 2Blakemore,
2014, Annu Rev Psychol
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Adolescent Depression: Who is at risk and why? 8
Bullying 20% report being bullied at school1
Much higher rates among LGBTQ youth2
risk for depression/suicidal ideation3
Cyber bullying
• 20-40% of kids are victims4
• Females and sexual minority youth at greater risk4
• risk for suicidality4
1CDC, 2014, MMWR Surveillance Summaries; 2CDC, 2009, YRBS Results;3Klomek et al., 2007, JAACAP; 4Aboujaoude et al., 2015, J Ad Health
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Adolescent Depression: Who is at risk and why? 9
Media Use Among Teens TV exposure may increase
depressive symptoms1
High screen time:
• exposure to unattainable body images, violence, normalization of drug/alcohol use2,3
• attention, obesity, school problems
AAP: <2 hours per day; screen free zones
Kaiser Study on Media Use (Rideout et al., 2010)
1Primack et al, 2009, JAMA; 2Stice, 2001, JSCP; 3Brown et al, 2002, J Ad Health
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Adolescent Depression: Who is at risk and why? 10
Sleep Media use associated with later bed
times and shorter sleep duration1
Teens need more sleep than adults2
25% report <6hrs of sleep3
Many hormones released during puberty affected by sleep4
Disrupted sleep is often a symptom but may also be a cause of depression in teens4,5
Earlier bedtimes may reduce risk of depression6
1Cain, 2010, Sleep Medicine; 2Carskadon, 2004, Ann N Y Acad Sci;; 3Wolfson, 1998, Child Dev.; 4Dahl et al, 2002, J Ad Health; 5Roberts, 2009, J Adol.; 6Gangwisch et al.2010, Sleep.
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Adolescent Depression: Who is at risk and why? 11
Who else is at risk for developing depression?
Teens with parents or siblings with depression1
Teens exposed to violence and abuse1
Teens experiencing stressful life events (divorce, death of a loved one) 1
LGBT youth2
Drug and alcohol users3 Teens with other physical or mental health problems1
1Birmaher et al., 1996, JAACAP; 2Marshall et al, 2011, JAH; 3Halfors, 2005, Am J Prev Med
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Adolescent Depression: Who is at risk and why? 12
Depressed adolescents have a higher risk for… Poor school outcomes1
Future, more severe depression1
Poor relationships1
Drug and alcohol use 1
Suicide
• 3rd leading cause of death2
• Suicide attempts: 2x higher in female teens in past year2
• Suicide: 4x higher in males; 77.9%2
• MDD most significant risk factor31Birmaher et al., 1996, JAACAP; 2CDC, 2015; 3Brent, 1993, JAACAP
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Adolescent Depression: Who is at risk and why? 13
Take Home Points
Rates of depression increase dramatically during adolescence Girls are at greater risk than boys Adolescence is a sensitive period of development with many social, physical,
and psychological changes the Social Brain Bullying, media use, and sleep patterns have important implications for
adolescent depression Some teens are at greater risk for depression because of their family history
and life experiences Adolescent depression has many negative effects on future outcomes
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What Does Depression Look Like in the Brain?
05/02/2023
Olga Tymofiyeva, PhDDepartment of Radiology and Biomedical Imaging
05/02/2023
“It is all in your head”
What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD 1
Brain ImagingMagnetic resonance imaging (MRI)
• safe• sensitive
05/02/2023What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD 3
k-spaceRadio-FrequencyPulsesGradientpulses Receivedsignal
Magnetic resonance imagingMRI image
Structural Functional (fMRI) Diffusion MRI
GRAY MATTER
WHITE MATTER
amygdala
striatum
prefrontal cortex
The Adolescent Brain: Still UnderConstruction
What does DEPRESSIONlook like in the brain?
• Hyperactive amygdala
• Smaller hippocampus
• Reduced striatal connectivity and response to reward
neural remodelin
g
Developmental events and
gender
Environment
(stressors, life events)
Genes
depressive episode
05/02/2023
Yes, “It is (mostly) in your head”
But it is as real as it gets
What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD 8
PLASTICITY
05/02/2023
Take Home Points
What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD 10
• MRI is a safe and sensitive method for studying the brain
• The brain does not fully mature till about 25 years old
• Brain of depressed adolescents (e.g. reward circuit) looks different
• Both, genes and environment shape the brain and may increase risk for depression
• Adolescence is also a window of opportunity: the brain is plastic, adaptive and changes with environment
Adolescent DepressionDiagnostics, current treatment strategies and future directions
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Eva Henje Blom M.D., Ph.D.Department of Psychiatry and the Osher Center for Integrative Medicine
Diagnostics of Adolescent Depression
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Depression
Genes & Biology
Context &Stressful events
Age & Gender
No single biomarker has been found for depression
Eva Henje Blom
We rely on self-rating and assessment from parents, teachers and clinicians
Eva Henje Blom28
The DSM system is used for diagnoses of mental disorders and based on symptom criteria
The DSM system does not take into consideration that
depression symptoms change across the life span and differ between genders
ADULTS TEENAGE GIRLS TEENAGE BOYS
Mood Sad, depressed Sad, depressed or irritable
Activity Inhibition Agitation
Sleep Early morning wake up Insomnia, delayed sleep phase
Appetite, weight Decreased appetite – weight loss Increased appetite - weight gain
Impulsivity Non impulsive behavior Impulsive behavior internalized:self-harming, binge eating
Impulsive behaviour externalized:behavioral problems, risk-taking, substance abuse
Symptom criteria of Major Depressive Disorder (MDD)
29 Eva Henje Blom
Required symptoms Depressed, sad or irritable mood and/ or a loss of interest or pleasure in daily activities Present for most of the time for more than two weeks Impaired function in daily life
Eva Henje Blom30
Signs to look out for in teenagers Insomnia & day-time tiredness
Increased irritability
Concentration difficulties
Bodily symptoms: headaches, stomach aches
Anxiety, worry, trouble relaxing
Binge eating – eating disorders
Self harming behavior
Behavioral problems – risk taking
Substance abuse
Current treatment strategies
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Eva Henje Blom32
Deal with a crisis here and now Manage life Create a sense of safety and hope An alliance that can be trusted Help regulate emotions and sleep Make sense for the adolescent, transparent
In the acute situation
Eva Henje Blom33
Cognitive Behavioral Therapy (CBT)
By identifying and challenging negative thinking such as rumination and worryingthe world may be perceived and interpreted in more functional ways
Top-down cognitive control of emotional processes
Interpersonal Psychotherapy (IPP)
Dialectic Behavioral Therapy (DBT)
Focuses on increasing social support and managing relationships that contribute to and maintain emotional stress
Learning behavior of both acceptance and changeAcceptance skills = being mindful and increase tolerance to distress Change-oriented skills = emotion regulation and interpersonal skills
Evidence-based psychological treatments
Eva Henje Blom34
Antidepressant drugs
Selective Serotonin Reuptake Inhibitors (SSRIs)are the most commonly used antidepressants for teenagers
14.2% of US teenagers with mood disorders are being prescribed SSRIs Ref: Merikangas et al. Medication use in US youth with
mental disorders. JAMA pediatrics. 2013
Fluoxetine (Prozac) is the only SSRI approved for teenagers
For teatment resistant depression other drugs are also being used
Less effective in teenagers compared to adults
It has not been proven that depression is caused by deficiency
of any specific neurotransmitter
Eva Henje Blom35
Side effects of SSRIs in adolescentsVery common: sleep disturbances
diarrhea, nausea
headache
tiredness
Common: sexual dysfunction
changes in appetite and weight
anxiety, restlessness
concentration difficulties
Specific to adolescents:
increased aggressive and violent behavior
increased suicidal ideation:
serious warning issued by FDA up through age 24
Important:
emotional blunting and indifference
symptomatic worsening during the first weeks of treatment
withdrawal symptoms at discontinuation
Future Directions
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Behavioral Activation (BA)
Targets behaviors that might maintain or worsen the depression to create positive change
Helps people understand environmental sources of their depression
Eva Henje Blom38
Shift away from rumination and worrying by practicing present-moment sensory and interoceptive awareness
Help recognizing emotions in the body and improve attention
Mindfulness-based skills
Mindfulness techniques are also applied in school based preventions such as Socio Emotional Learning (SEL)
Eva Henje Blom39
Find out what you value the most in your life
Challenge patterns of emotional avoidance
Acceptance Commitment Therapy (ACT)
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Training for Awareness Resilience and Action TARA
TARA is developed at UCSF and based on
current neuro-scientific findings of adolescent
depression and brain development
Targets primarily amygdala hyper-reactivity and improve
emotion regulation and attention skills through bodily practices
such as breathing and slow movement
TARA is currently being tested with behavioral and
neuroimaging outcomes as part of the BrainChange Study
Eva Henje Blom41
Connection & Trust
Cultural humility Empathic listening Authenticity Seek support Give the rationale
Maintain connection even when being dismissed