1. Diagnosis and Treatment of Major Depression in Adolescence
David L. Fogelson, M.D.
Clinical Professor of Psychiatry
David Geffen School of Medicine at UCLA
And The Semel Institute for Neuroscience and Human Behavior at UCLA

2. Defining Depression D
Dep Symptoms
Dep Disorder
©JR Asarnow2010

3. Mary Presents with frequent school absences Stomach aches
Difficulty sleeping due to stomach pain
Missing school frequently
Sad nearly all the time
Recent onset of the following symptoms
Can’t sleep at night
Not eating well
Can’t concentrate at school, drop in grades
Tired
Feels worthless
Thoughts of death and suicide
Is Mary suffering from:
Major Depression
Dysthymic Disorder
A depressive adjustment
Disorder
None of the above
Answer a.

4. Clinical Depression: Major Depression
Duration
≥ 2 weeks
Critical Symptoms
Depressed, irritable , or anhedonic mood nearly all the time
# Symptoms- 5 of 9 symptoms must include depressed/irritable mood or anhedonia
Depressed/Irritable Mood
Anhedonia
Insomnia or hypersomnia
Appetitie disturbance
Concentration problems/indecision
Low energy or fatigue
Worthlessness or guilt for no reason
Agitation or moves more slowly than usual
Thoughts of death or suicide
Severity
Distress or functional impairment
EXCLUSION
Not due to drugs/medication/medical disorder. Not bereavement, not a mixed episode

5. Diagnosis-Specific Severity Assessment: PHQ-9, symptoms in Major Depression
David L. Fogelson, M.D., June 2013

6. Danny Getting into trouble at school
Does Danny suffer from:
Major Depression
Dysthymic Disorder
Bipolar Disorder
Oppositional Defiant Disorder
None of the above
Answer b.
Getting into trouble at school
Irritable and crabby at home, been generally unhappy for past year
Complains of being bored all of the time
Feels like not as good as other kids
Can’t concentrate in school, drop in grades
Says his life is awful, no reason to think it will get any better, feels like giving up

7. Clinical Depression: Dysthymic Disorder
Duration
≥1 year for children
Critical Symptoms
Depressed/ irritable mood most of the time more days than not
# Symptoms- 2 of 6 symptoms, must include depressed/irritable mood
Either overeating or lack of appetite.
Sleeping too much or having difficulty sleeping.
Fatigue, lack of energy.
Poor self-esteem.
Difficulty with concentration or decision making.
Feeling hopeless.
Severity
Distress or functional impairment
EXCLUSION
No MDD in Year 1.
Never manic/hypomanic/mixed/ cyclothymicNot due to psychosis, drugs/medication/medical disorder. Not bereavement

8. Ana
Presents to ER with suicide attempt, serious overdose Boyfriend broke up with her Hasn’t been able to stop crying since break-up 5 days ago Feels worthless Can’t sleep Doesn’t feel like eating Worried that she is pregnant, feels nauseous
Anna suffers from Major Depression.
Depression is
Extremely rare in teens, <.1%
Rare, < 1%
Low frequency, 1-2%
Common, 5-6%
Answer d.

9. Children do suffer from depressive disorders: Pediatric depression is a prevalent condition
Rates increase with age; pattern differs by gender
<13 yrs: 2.8% (+ .5)
13-18 yrs 5.6% (+ .3)
1:1 sex ratio (or more boys) prior to adolescence
Increased frequency in girls during adolescence
13-18 yrs girls 5.9%
13-18 yrs boys 4.6%
Rates approach adult prevalence by end of adolescence
After the first episode of depression remits the
risk for a second episode is approximately:
a. 10%
b. 30%
c. 50%
d. 70%
Answer c.

10. Pediatric Depression Not Benign Condition
Depression recurrent (in up to ~60-75% of cases),
20% have persistence >2yrs
40-60% relapse after successful treatment
70% have adult depression
Episodes are lengthy: MDD (7-9 mos) in clinical cases; Double Depression (~3yrs)
Associated with significant impairment in school, with family, and peers
Suicide risk in adults with history of adolescent MDD is 5x adults with late onset
Asarnow et al., 1994; Kovacs et al., 1984a, 1994,1997; Lewinson et al., 1994; McCauley et al., 1993; Puig-Antich et al., 1989; Rao et al., 1995; Weissman et al., 1999 a,b

11. Elevated rates of Suicide & Suicide Attempts in Adolescent-Onset MDD by Early Adulthood
From Weissman et al. (1999). Depressed Adolescents Grown Up. JAMA
Mean age at follow-up 26 yrs, follow-up period ≈10 years

12. Comorbidity/Co-Occurring Disorders: High Across Range of Disorders
Most youths present with another diagnosis, ~80-90%
40-50% have an anxiety disorder, anxiety disorders often precede the onset of depressive disorders
Double depression common, ~ 20% DD/MDD
ADHD comorbid in ~ 20%
Conduct disorder in ~ 50% of school age depressives
Increased risk for bipolar disorder (8%-49%)
Common overlap with PTSD, OCD
Baji et al., in press; Biederman et al., 1995; Carlson & Kashani, 1988; Ferro et al., 1994; Fombonne et al., 2001; Geller et al., 2001;
Goodyer et al., 1997; Kovacs et al., 1988/89, 1994, 1997 and Unpub; McCauley et al., 1993; Mitchell et al., 1988; Rao et al., 1995;
Ryan et al., 1987; Shain et al., 1991; Strober & Carlson, 1982; Strober et al., 1993; Weiss & Garber, 2003; Weissman et al., 1999a,b

13. TREATMENT
Do we have effective treatments?

14. Treatment for Depression in Children and Adolescents
Psychotherapy
Pharmacotherapy
Combination psychotherapy and pharmacotherapy
Studies in Children and Adolescents indicate that the most
Effective treatment for Depression is:
Psychotherapy
Pharmacotherapy
Combination Psychotherapy and Pharmacotherapy
None of the above are better than placebo answer c.

15. Fluoxetine Treatment for Depression in Children and Adolescents
Remission Rates
Fluoxetine 41%
Placebo %
p<0.01; Emslie GJ, Heiligenstein JH, Hoog S, et al. J Am Acad Child Adolesc Psychiatry. 2000

16. Drug Treatments for Child and Adolescent Depression: Levels of Evidence
Short-Term
Efficacy
Fluoxetine
Sertraline
Fluvoxamine
Paroxetine
Citalopram/Escitalopram
TCAs
Venlafaxine
Duloxetine A B C
A * *
Because meds
pose a risk for
suicide, they
should:
Never be prescribed
Monitored carefully during
the first month of treatment
Avoided in Bipolar
Depression
B & C are correct
Answer d.
A = >2 randomized, controlled studies; B = 1 randomized, controlled study; C = Clinical experience (open studies, case reports, etc)
*-- fluoxetine FDA approved for depression ≥ 8 yrs; Escitalopram >
Adapted from Jobson KO, Potter WZ. Psychopharmacol Bull. 1995;31:457–459.
Adapted from McCracken, 2009

17. FDA Public Health Advisory March 2004
Suicidality in Children and Adolescents Treated With Antidepressant Medications
Today the Food and Drug Administration (FDA) directed manufacturers of all antidepressant drugs to revise the labeling for their products to include a boxed warning and expanded warning statements that alert health care providers to an increased risk of suicidality (suicidal thinking and behavior) in children and adolescents being treated with these agents, and to include additional information about the results of pediatric studies.

18. What kind of depression treatment do teens prefer?
21%
27%
52%
Jaycox, L.H., Asarnow, J.R, Sherbourne, C.D., et al. (2006). Adolescent Primary Care Patients’ Preferences for Depression Treatment. Administration and Policy in Mental Health 33,
© Joan R. Asarnow for YPIC Team

19. Cognitive Behavior Therapy (CBT)
Established psychosocial treatment for adolescent depression with evidence based supporting efficacy
Acute treatment studies demonstrate greater efficacy for CBT (12-16 sessions) as compared to alternative psychosocial interventions and waitlist conditions
Response rates for CBT appear to be between 60-66% (vs % in comparison conditions)
Although we focus on CBT today, there are accumulating data supporting other psychotherapies (e.g. IPT)

20. Psychotherapy Trial: MDD Remission (No MDD + BDI <9 for 3 Weeks)60 50 40 30 20 10
CBT (N=35)
Family (N=31)
Supportive (N=33)
Overall p=0.05; CBT vs. family p=0.03; CBT vs. supportive p=0.04
Brent DA, Holder D, Kolko D, et al. Arch Gen Psychiatry. 1997(Sep);54(9):
Courtesy, McCracken, 2009

21. Adolescent Depression
Combined CBT + Medication Treatment of Choice for Moderate to Severe Major Depression
N=439, Treatment of Adolescent Depression Study (TADS); Week 12 Acute Treatment Response

22. TADS Recovery Incomplete: Remission Rates are Low & 50% of Remitted Youths Had Residual Symptoms
*CDRS-R total score ≤28 as the criterion for remission. COMB> FLX,CBT, PBO, P=.0009; FLX=CBT=PBO
Kennard et al. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry Dec;45(12):

23. 6-Site NIMH Study MH61835 Pittsburgh, Brent MH61864 UCLA, Asarnow MH61856 Galveston, Wagner
MH61869 Portland, Clarke
MH61958 Dallas, Emslie
MH62014 Brown, Keller
334 outpatient adolescents, ages years, with diagnosis of major depression
Depression persists despite at least 6 weeks of SSRI treatment
Acute phase 12-week trial
JAMA Feb 27, 2008

24. TORDIA Supports Value of CBT-Clinical Response by Treatment Group%
JAMA Feb 27, 2008
CBT vs none, 54.8% vs 40.5%, p<0.009