Mental Health in Adolescents

Dr. Nevine Estaphan

Dr. Samira Khan

Child and Adolescent Psychiatry Fellow

Department of Behavioral Medicine and Psychiatry

West Virginia University

Pediatric Depression

Depression in Primary Care

• Adolescent depression often identified by PCP’s• shortage of mental health providers

• perceived stigma

• lack of adequate healthcare coverage

• Many feel inadequately trained, supported, and reimbursed• Untreated depression → suicide

Epidemiology

• Prevalence of depression

• 1-3% in prepubertal children

• 3-8% in adolescents

• However, lifetime prevalence of MDD in

adolescents as high as 18% in one study

• Adult depression has roots in adolescence

• Before puberty -> 1:1 ratio

• During adolescence -> 2:1 ratio for girls

• 70-80% of adolescents do not receive treatment

Risk factors

• Genetic predisposition - 1st degree relatives

• Parental depression may be a contributing factor

• Abuse and neglect

• Previous depressive episodes

• History of anxiety disorders, ADHD, learning disabilities,

and early losses

• Family dysfunction or caregiver-child conflict

• Peer problems

• Academic problems

• Negative style of interpreting events or coping with stress

• Chronic illness

Criteria for Major Depressive Disorder

(MDD)

• Asterisk symptoms must be present for most of the day nearly every day for at least 2 weeks, with other symptoms present during the same period

• Must have 5 (SIGECAPS):• Depressed or irritable mood*• Anhedonia in almost all activities*• Change in appetite/weight• Insomnia or hypersomnia• Psychomotor agitation or retardation• Fatigue/poor energy• Feelings of worthlessness or guilt• Impaired concentration• Recurring thoughts of death or suicide

• Persist and cause significant distress or interfere with basic functioning

Criteria for Dysthymic Disorder

• Symptoms less intense, but more persistent than MDD

• Chronically depressed or irritable mood for at least one year plus at least 2 of the following:• Appetite disturbance• Sleep disturbance• Fatigue• Low self esteem• Poor concentration• Difficulty making decisions• Feelings of hopelessness

• In adolescents, disobedience and feelings of inadequacy and irritability

Course and Comorbidity

• Typical major depressive episode is 7-9 months and 90% remit within 2 years• Earlier age of onset → lengthier and more severe course

• Median dysthymic episode is 4 years• Relapse is common (40% by 2 years, 70% by 5

years)• 40-70% have comorbid psych disorders

• Substance use• Anxiety disorders• Abuse• Disruptive behavior disorders (ADHD, ODD, conduct

disorder)• Eating disorders• Learning disorders

Differences from Adults

• Lack emotional and cognitive ability to identify

emotional experiences

• Report somatic complaints

• Depressed mood inferred from observation instead of

patient’s report

• Irritable → feel “annoyed” or “bothered”, “unfair”

• Negative, argumentative, pick fights

• Find others antagonistic or uncaring

Differences from Adults

• Mood reactivity → cheered up by positive events

• Promiscuity, thrill seeking, substance use to temporarily lift

mood

• Anhedonia → “stupid” or “uninteresting,” pervasive

boredom

• Withdrawal from social activities

• Appetite → failure to make expected weight gain or

weight loss

• Psychomotor retardation alternating with agitation →

restless, pacing, tantrums, hand wringing

Differences from Adults

• Worthlessness → feelings of inadequacy, inferiority, failure, and worthlessness, “I don’t care”, fear of failure, self-critical• Most do not directly acknowledge such negative self

perceptions

• Concentration → take longer to complete schoolwork

• Thoughts of death → music and literature with morbid themes

Evaluation

• Difficult due to nonspecific symptoms,

comorbidities, and broad differential

• Ask questions in a nonstigamatizing and

normalizing way

• Observe for depressed affect

• Diagnosis → clinical interview plus information

from caregivers (Essential!)

Evaluation

• Assess for SI/HI and risk and protective factors• Ask direct questions

• Ask about abuse and substance use

• Look for comorbidities and possible medical causes

• Look for precipitants, stressors, academic, social, and family functioning• Will guide treatment that targets symptoms

Evaluation

• Recommend referral to specialist for:• Recurrent or chronic depression, esp. if lack of response

to initial course of treatment

• Complicating psychiatric comorbidities, incl. substance use

• Marked functional impairment

• Psychosocial factors likely to maintain the depression (i.e. significant family discord)

• If diagnosis is unclear

• If patient is very guarded

• Suicidal ideation or history of suicide attempt

• Family unable to monitor safety

• Uncomfortable managing pediatric depression

Treatment

• Requires involvement of the parents/guardians

• Psychoeducation is important and should involve the family!!• Decreases likelihood of withdrawal from treatment

and reduces stigmatization

• Understand depression as an illness

• Address psychosocial deficits

• Role of medication in treatment

• Benefits, risks, side effects

• Lag in onset of therapeutic effect

• FDA black box warning

Psychoeducation

• Importance of treatment compliance

• Some kids cannot swallow pills

• Misunderstandings

• Perceived lack of need for treatment

• Failure to understand the disorder

• Lack of money

• Misunderstanding instructions

• Complex schedules of drug administration

• Limit access to means of self-harm

Treatment Studies

• Few well designed controlled trials of treatments

for adolescent depression

• Current practice guidelines based on studies in

depressed adolescents, adult depression

research, and clinical experience

• Much psychopharmacology use is off label for

children

• Should inform family of this and stay current on

literature supporting off label use of drugs

Types of Interventions

• Psychosocial → understand the nature of depression and manage stressors • CBT, interpersonal, family, dynamic, group, and

supportive

• Only CBT and interpersonal therapy are evidence based

• Pharmacologic → include SSRI’s and others

• Combination → superior to monotherapy• Monotherapy with SSRI reasonable in moderate to

severe depression if access to CBT may be delayed

• ECT → last resort, but effective; can be used in pregnancy

Treatment

• For nonpsychotic depression, psychotherapy is the first treatment for at least 4-6 weeks • Early onset mood disorders affect development, even

after spontaneous remission or successful treatment

• Both patients and families benefit from instruction in relapse prevention techniques

• Social withdrawal and limited peer relationships may respond to behavioral modification and social skills training

• Two major NIMH studies

Treatment for Adolescents with

Depression Study (TADS)

• Evaluated efficacy of treatment with prozac(fluoxetine), CBT, prozac plus CBT, or placebo in adolescents with MDD

• Supports short-term combination therapy (CBT plus prozac)

• Combination protective against harm-related adverse events

• Remission more frequent in the combination group at 12 weeks

• At 36 weeks, remission rates in all groups ~ 60%• Recovery earlier in combination therapy and prozac alone

• Prozac alone → increased suicide related events

• Combination therapy improved functioning, global health, quality of life

• Prozac improved only functioning

Treatment

• If suicidal ideation is present, close supervision and hospitalization may be necessary

• Typical response rate to initial monotherapy with psychosocial or pharmacologic interventions is approx 60% with a remission rate between 35-40%• Pharmacotherapy is generally not sufficient as the sole

treatment because of environmental and social problems that often remain after mood has stabilized

• Combination treatment increases likelihood of improving family and peer relationships, increasing self esteem, coping skills, and adaptive behaviors

Take Home Points

• Suicidal ideation is a medical emergency, but emergent administration of antidepressants has no role in the acute management

• There are risks associated with any treatment or medication, but also risks related to untreated depression• Untreated depression has the highest risk of morbidity

and mortality

• Ask about past manic symptoms because 2/3 of bipolar disorders initially present with depression

Pediatric Anxiety & OCD

Why is this important?

• Anxiety is common - whether as a symptom or diagnosis, patient or parent.

• Can be disabling• Impacts self-esteem, relationships & academics

• Easily misdiagnosed

• Many anxiety symptoms are responsive to treatment.

• In the US, the cost of mental disorders among persons <24 yo is estimated at $247 billion annually.

Representative?

ADHD, 6.80%

ODD/CD, 3.50%

Anxiety, 3.00%

Depression, 2.10%

Autism, 1.10% Tourette's, 0.20%

Parent Reported Diagnoses - US 2005-2011

ADHD

ODD/CD

Anxiety

Depression

Autism

Tourette's

What is anxiety?

• There are many varieties of anxiety that affect both children and adults:• Separation Anxiety Disorder

• Selective Mutism

• Panic Disorder (+/- agoraphobia)

• Specific Phobia

• Social Anxiety Disorder

• Obsessive Compulsive Disorder

• Posttraumatic Stress Disorder

• Acute Stress Disorder

• Generalized Anxiety Disorder

• Substance induced anxiety disorder

Anxiety

• There are yet other disorders that may have symptoms of anxiety as a component of their presentation:• Organic disorders (i.e. cardiac, endocrine, infectious, etc)

• Pervasive developmental disorders

• Tic disorders

• Attachment disorders

• Substance use disorders

• Mood disorders

• Psychotic disorders

• Gender identity disorders

• Eating disorders

• Paraphilias

• Personality disorders

• Etc, etc, etc.

Symptoms of Anxiety

• Behavioral• Avoidance

• Crying

• Clinging

• Freezing

• Nail biting

• Defiance

• Anger/irritability

• Difficulty sleeping

• Academic failure

• Repetitive acts or compulsive behaviors

• Poor concentration

• Cognitive• Cognitive distortions

(“What ifs?”)

• Obsessions

• Catastrophizing

• Overestimating

• Physiologic• GI distress

• Headaches

• Muscle tension

• Sweating

• Choking

• Inability to breathe

• Jittery

Normal anxiety

Age Common Anxieties

Infancy Environmental stressors (noises, loss

of physical support, startling)

* Stranger anxiety begins ~ 8 months,

peaks at 24 months

Toddlers / Preschool Monsters, darkness (bedtime),

magical thinking

* Separation anxiety peaks ~ 14-18

mos.

Early school-age (6-9 years old) Animals, weather (lightning/thunder)

Late school-age (9-12 years old) Fears from TV, death/personal injury,

school/tests

Teenagers Competence, personal appearance,

home issues, school issues (i.e.

peers), politics

Prevalence & Epidemiology

• Overall, anxiety disorders are one of the most

common mental health conditions affecting

youth.

• Prevalence 6-20% in community samples, varying by

diagnosis.

• Overall, girls > boys

• OCD is exception (girls = boys)

• Neurologically based within fear & reward

circuits – striatum, amygdala, orbitofrontal

cortex, anterior cingulate cortex.

Risk Factors

• Family history• Highly heritable supported in twin studies

• Temperament• Inhibited children have increased risk for anxiety

• Environmental• Parental anxiety (models anxious coping)

• Over-control (limits child’s autonomy/mastery)

• Attachment• Insecure & anxious/resistant attachments are

associated with developing anxiety disorders

Basic Anxiety Comorbidities

• Highly co-morbid1. Other anxiety disorders

• 68% of children with selective mutism meet criteria for social phobia.

• Social phobia, specific phobia often co-occur with school refusal

• Depression (8.2 x more likely)

• Link between GAD & depression persist into adulthood

2. Bipolar Disorder

• Comorbid anxiety associated with lower likelihood of recovery

3. Substance use disorders

4. Other externalizing disorders (ADHD, CD/ODD)

• 30% with ADHD have anxiety.

Positive Predictors for Treatment

Outcome in Anxiety

• Older age at onset

• Lesser severity of symptoms

• Intact family functioning

• Less parental psychopathology

Separation Anxiety Disorder

• Prevalence ~ 3.5-4.7% children, 0.7-2% adol

• Normal developmental milestone of infancy

• Appears 6-8 mos, peaks 10-18 mos, diminishes by 2-

3 years

• Usually begins around age 6

• Girls > Boys

• Potential risk factor for development of panic

disorder as an adult (mixed evidence)

Separation Anxiety Disorder

• Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom they are attached as evidenced by ≥ 3 of:• Distress upon separation from home or major attachment figures

• Worry about losing attachment figures

• Worry about untoward event leading to separation

• Reluctance to go to school/elsewhere due to fear of separation

• Reluctance to be alone without attachment figure

• Refusal to go to sleep unless near to major attachment figure

• Repeated nightmares focusing on separation

• Physical symptoms when separation occurs or is anticipated

• Occurs for at least 4 weeks in patient ≤ 18 yrs old

• Clinically sig distress or impairment in functioning

Selective Mutism

• RARE; Prevalence < 1%; Girls > Boys

• Usually seen between 3-8 years old

• Highly comorbid with language/communication

disorders & social phobia

• Consistent failure to speak in specific social situations

but can speak in other situations

• Interferes with expected achievement

• At least 1 month (not limited to first month of school)

• Not due to lack of knowledge or comfort with spoken

language

Social Phobia

(aka Social Anxiety Disorder)

• Prevalence ~ 0.9-1.6% children, 1.1% adol

• Shown to have poorer social skills and functional

limitations (fewer friends, lower participation in

activities, use of avoidant coping)

• Benefit from social skills training in addition to

therapy

Social Phobia

• Marked and persistent fear of one or more social situations where exposed to unfamiliar people or to possible scrutiny by others. Fears that he will act in a way that will be embarrassing• * Must have capacity to form age appropriate social relationships with

familiar people with anxiety occurring in these situations

• Exposure to feared situation provokes anxiety• * May be expressed by crying, tantrums, freezing or shrinking away

• Recognition that fear is excessive / unreasonable• * Not always the case (or required) for children

• The feared situation is avoided or endured with intense distress

• Interferes significantly

• If < 18 yrs old, must occur for at least 6 months.

• Not due to direct effects of substance or medical condition

School Refusal

• Not a formal DSM-IV TR diagnosis; however, it is important because may be indicator of other anxiety disorder (esp social anxiety disorder, specific phobia, separation anxiety)

• Requires differentiation from other sources of refusal (to include truancy which may be related to wide variety of issues)

• Key is to identify reason for refusal and ultimately return to school as soon as possible.

Generalized Anxiety Disorder

• Prevalence ~ 2.7-4.6%

• High rate of chronicity once treated, symptoms

are fluctuant with stress

• Often is related to what would be age

appropriate worries, but is in EXCESS of what is

expected

• Competence, social / peer relationships, academics,

previous actions, identity

Generalized Anxiety Disorder

• Excessive worry occurring more days than not for at

least 6 months about numerous events

• Difficult to control/stop worry

• Associated with 1+ symptom in kids (3+ in adults):

• Restlessness, keyed up, on edge

• Easily fatigued

• Difficulty concentrating

• Irritability

• Muscle tension

• Sleep disturbance

Specific Phobia

• Prevalence ~ 2.4-3.3%

• Girls > Boys

• Most prevalent anxiety disorder in pre-pubertal

children

• Hundreds of different kinds

• Grouped into five types: animal type, natural-

environmental type, blood-injection-injury type,

situational type, and “other” type.

Specific Phobia

• Marked and persistent fear that is excessive or unreasonable cued by presence/anticipation of specific object / situation.

• Exposure to stimuli almost invariably provokes anxiety• * May be expressed by crying, tantrums, freezing or shrinking

away

• Recognition that fear is excessive / unreasonable• * Not always the case (or required) for children

• Phobic situation is avoided or endured with intense distress

• Interferes significantly or is marked distress

• If under age 18 yrs old, must persist for at least 6 mos.

Panic Disorder

• Prevalence ~ <1% children, 0.6-4.7% adol

• General age of onset is adolescence (~ 14 yo)

• Criteria• Recurrent unexpected panic attacks

• Discrete period of intense fear AND 4+ symptoms (heart racing/palpitations, sweating, shaking, dyspnea, choking, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control/going crazy, fear of dying, paresthesias, or chills/hot flashes)

• Followed by at least 1 month of either persistent worry of another attack OR worry about implications of attack OR change in behavior due to attack.

• With or without agoraphobia (anxiety about being in places where escape may be difficult thus causing avoidance or anxiety)

Suicidality

• After controlling for other disorders, anxiety

depression & disruptive behavior disorders are

still independently associated with suicidality

(Foley et al, Arch Gen Psychiatry 2006; 63:

1017-1024)

OCD• Alex, 5, can't go to sleep until he kisses his mother five times

on each cheek after she closes his closet in a certain way. He has no other fixed behaviors.

• Jesse, 10, cleans his teeth so frequently that he uses a box of toothpicks each week and his gums bleed profusely. Each day he uses a half box of Q-tips to clean his ears and a roll of toilet paper when he goes to the toilet.

• Ashley, 16, reports that each time she leaves a classroom, passes the principal's office or leaves school, she has to imagine the number 12 on a clock and say the words "good luck" to herself. She reports that she can't stop thinking about the words "good luck." If she tries to stop herself from thinking about these words, she becomes very anxious and worries that she'll have a heart attack. Before going to sleep, she closes the bedroom door four times, turns the lights on and off four times and looks out the window and under her bed twelve times.

http://www.aboutourkids.org

Obsessive Compulsive Disorder

• Often referred to as a “Hidden epidemic”

• Girls = Boys

• Highly heritable

• Child & adolescent prevalence ~ 1-2%

• Often highly co-morbid with other illnesses in childhood and into adulthood• Depression (8-73%)

• Anxiety disorders (13-70%)

• Disruptive disorders (3-57%)

• Tic disorders (13-26%)

OCD

A. Presence of EITHER obsessions or compulsions:

• Obsessions defined by: recurrent thoughts, impulses, or

images experienced as intrusive, inappropriate &

distressing; AND not excessive worries about real-life

problems; AND attempts to ignore/neutralize them; AND

recognizes they are a creation of their own mind.

• Compulsions defined by: repetitive behaviors that they feel

driven to perform in response to obsession or rigid rules;

AND compulsions are aimed at preventing/reducing

distress or preventing dreaded event but are not actually

realistically connected.

OCD

B. Realized that they are excessive or

unreasonable

• *doesn’t apply to children

C. Cause marked distress, are time consuming

(>1h/d), or significantly interfere

D. Not restricted to other Axis I disorder’s

obsessions (trichotillomania, AN, drugs)

OCD

• Typically have both O & C, but if only one, then

obsessions are more common.

• Objects/content of symptoms can change over

time.

• Adolescents’ obsessions typically focus on

contamination, fears of ill fate befalling loved

one, exactness/symmetry, and religion

OCD

• Family response is critical

• Often families delay treatment with hope that

symptoms will extinguish if people aid in performing

activity (thus perpetuating entanglement into rituals).

OCD Cycle

OCD

• Elevated concordance rates among

monozygotic compared to dizygotic twins with

higher rates of OCD (& Tourette’s Disorder) seen

in 1st degree relatives

• Small subset of children with atypically acute

onset symptoms (within 24-48 hrs)

• PANDAS vs PANS

PANDAS (or PANS)

• Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus

• First published/discussed in 1998

• Abrupt onset of OCD (or tic) symptoms in prepubertal child after Group A beta-hemolytic streptococcal infection; relapsing/remitting course associated with neurologic abnormalities (choreiformmovements, motoric hyperactivity)

• Caused by autoimmune response in which antibodies against beta-hemolytic strep cross react and attack the basal ganglia (caudate nucleus, putamen, globus pallidus)

PANS

• Recent research article has suggested change to a broader term (Pediatric acute-onset neuropsychiatric syndrome (PANS) –excludes infectious etiology, focus more on homogenous group with similar symptoms in order to avoid exclusion

• Not yet validated in clinical practice

• Discussed by Swedo, Leckman & Rose• Identified by 3 research criteria

1. * Abrupt, dramatic onset of OCD or severely restricted food intake

2. Not better explained by other neuro/med disorder (Sydenham’s chorea, lupus, Tourettes)

3. Concurrent presence of additional neuropsych sx with similar severe/acute onset (≥2)• Anxiety; emotional lability and/or depression; irritability/aggression/oppositionality;

behavioral regression; academic deterioration; sensory/motor abnormalities; somatic sx (sleep change, eneuresis, urinary frequency)

Anxiety Clinical Assessment

• What are they presenting with now?• SEE ALONE and with parent.

• Historical information• Developmental history

• PMH

• Family History

• Social History

• Current Medications

• Physical examination / labs

• Collateral Information (teachers, family, scales)

Medical Evaluation

• Medications (antiasthmatics, steroids, sympathomimetics, herbals, OTCs – diet pills, antihistamines or cold meds)

• UDS, caffeine

• Endocrine (hyperthyroidism, hypoglycemia, hyperadrenocortisolism, pheochromocytoma)

• Cardiac (arrhythmias, PE)

• Respiratory (asthma, pneumonia)

• Hematologic (porphyrias, lead intoxication)

• Neurologic (epilepsy, migraines, encephalitis, vestibular dysfunction)

Helpful screening questions…

• Do you worry more than other teens you know?

• Does worry/anxiety ever stop you from doing things?

• Are there any events/people that you avoid because of fear or anxiety?

• Have you ever missed school or had to come home from school early because you were worried or afraid?

• Have you ever had times where your heart was racing or you thought you might be dying?

• Do you get a lot of stomach aches and headaches?

• Do you have trouble concentrating?

• Do you have ideas or images that come into your mind and you can’t control them?

• Do you have any routines that you have to do to make yourself less worried?

• Do you have a favorite number?

• Is it hard to go to sleep because you can’t turn off your thoughts?

Treatment – Anxiety Disorders

• Multimodal treatment approach

• Education of parents & child

• Consultation with school, pediatricians

• Therapeutic interventions

• CBT

• Family therapy

• Psychopharmacologic intervention

Family Involvement

• Studies have supported that level of anxiety

decreased more when parents were included

(whether in treatment of parental anxiety, parent

training / education) as compared to individual

CBT alone

• Education

• Encouraging verbalization of feelings

• Family Therapy

• Appropriate modeling

Social Interventions

• Social Skills Groups

• Group Therapy

• School modifications

• IEP vs 504 plan

• Testing modifications – quiet environment

• Homework – length modified

• Classroom positioning

• Access to counselors, education of teachers

CBT

• Important to include family as they can be reinforcers/coaches at home

• Flexibility & rapport are important – patient will likely be uncomfortable discussing topic.

• Can be manualized

• CBT techniques varied depending on diagnosis (ex: graded exposure in social phobia vs. exposure response prevention for OCD)

• Number of studies show short term & long-term gains maintained at 1 year & beyond; however, 20-50% may continue to meet criteria for an anxiety disorder despite CBT.

Cognitive Behavioral Therapy

• Coping Cat• CBT treatment for GAD,

separation anxiety & social phobia in children ≥ 7 years old.

• Weekly sessions with child, separate parent sessions.

• Identification of anxiety & physical responses, teaches components of progressive muscle relaxation/deep breathing, development of appropriate coping plan, rate efficacy

Therapy for OCD

• Well documented improvement with specific

forms of CBT

• Exposure with Response Prevention

• CBT alone is not as effective as CBT + ERP

Exposure Response Prevention

• Identification of fear hierarchy

• Development of effective coping strategies

• Exposure to thoughts/images/objects that trigger anxiety (based upon hierarchy)• Maintain exposure until anxiety peaks and subsequently

decreases

• “Response Prevention” – during exposure or following exposure, patient does not engage in compulsive behaviors.

• The natural drop in anxiety that happens with continued exposure and response prevention results in habituation to the stressor

Use of medications?

• Need for more acute symptom reduction than

therapy alone could provide (in moderate to severely

anxious child)

• Therapy alone isn’t effective due to profound anxiety

• Presence of co-morbid disorder that requires

treatment

• Partial response to therapy alone

• Benefits vs risks weighed & considered

• Impairment of child has increased to degree that

intervention needed

STUDIES – CAMS Study

• “Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety” (Walkup et al, N Engl J Med 2008; 359:2753-2766)

• 488 children, ages 7-17

• Diagnoses included Separation Anxiety Disorder, GAD, or social phobia

• 14 session of CBT, Zoloft (up to 200 mg/d), combo of both or placebo drug x 12 weeks.

• The percentages of children who were rated as very much or much improved on the Clinician Global Impression–Improvement scale were:

• 80% for combination therapy

• 60% for cognitive behavioral therapy

• 60% for sertraline

• 24% for placebo

Psychopharmacology - OCD

• Response rates to meds alone vary per study –studies show that 40-50% of drug naïve patients experience a 25-40% reduction in symptoms with meds; shows need for dual treatment

• Aims are to reduce/improve symptoms as rarely do all symptoms resolve

• After symptom resolution / improvement, continue to treat for 9-18 months, then gradually taper med (25% every 1-2 months) to see if symptoms return.

Questions?

Resources

• AACAP (www.aacap.org)• FDA

(www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/UCM096273)

• GLAD-PC Toolkit (www.thereachinstitute.org/files/documents/GLAD-PCTooklit.pdf )

• National Alliance for the Mentally Ill (www.nami.org)

• NIMH (www.nimh.nih.gov/health/topics/depression/index.shtml)

References

• Albers, L.J., Hahn, R.K., and Reist, C. (2011). Handbook of Psychiatric Drugs. Blue Jay, CA: Current Clinical Strategies Publishing.

• Bonin, L. (2009, Jun 3). Psychopharmacological treatment for adolescent depression. Retrieved from http://www.uptodate.com/contents/depression-in-adolescents-epidemiology-clinical-manifestations-and-diagnosis?source=search_result&search=Depression+in+adolescents%3A+epidemiology%2C+clinical+manifestations%2C+and+diagnosis&selectedTitle=1%7E150

• Brent DA, Emslie G, Clarke G, et al: Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA 299:901-913, 2008.

• Brent DA, Emslie G, Clarke G, et al: Predictors of spontaneous and ssytematically assessed suicidal adverse events in the treatment of SSRI-resistant depression in adolescents (TORDIA) study. Am J Psychiatry 166:418-426, 2009.

• Dulcan, M., Martini, R., & Lake, M. (2003). Child and adolescent psychiatry. (3rd ed.). Arlington, VA: American Psychiatric Publishing, Inc.

References

• March J, Silva S, Petrycki S, et al: fluoxetine, cognitive behavior therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 292: 807-820, 2004.

• March J, Silva S, Petrycki S, et al: The Treatment for Adolescents with Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry 64:1132-1143, 2007

• Moreland, C., & Bonin, L. (2012, Jan 16). Psychopharmacological treatment for adolescent depression. Retrieved from http://www.uptodate.com/contents/overview-of-treatment-for-adolescent-depression?source=search_result&search=Overview+of+Treatment+for+Adolescent+Depression&selectedTitle=1%7E150

• Moreland, C., & Bonin, L. (2012, Jul 2). Psychopharmacological treatment for adolescent depression. Retrieved from http://www.uptodate.com/contents/psychopharmacological-treatment-for-adolescent-depression?source=search_result&search=Psychopharmacological Treatment of Adolescent Depression&selectedTitle=1~18

Sources

• Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition, Text Revised.

• Lewis’s Child & Adolescent Psychiatry, 4th edition, © 2007.

• Kaplan & Sadock’s Synopsis of Psychiatry, 9th edition, © 2003.

• AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With Obsessive-Compulsive Disorder, January 2012.

• AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders, February 2007.

• Psychopharmacology of Pediatric Anxiety Disorders, Lauren Swager, MD.

• Pharmacotherapy of Pediatric OCD, Lauren Swager, MD.

• Anxiety Disorders in Children and Adolescents, Lauren Swager, MD.

• Diagnosis and Treatment of Anxiety Disorders in Children & Adolescents, Jeffrey Strawn, MD.

• “Mental Health Surveillance Among Children – United States, 2005-2011,” MMWR, May 17, 2013, Vol 62, No 2.