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

11/16/2015

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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05/02/2023Eva Henje Blom37

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)

05/02/2023Eva Henje Blom40

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