Clinical Pearls & Morning Reports
Depression in adolescence predicts depression and anxiety in adulthood, and most affected adults had their first depressive episode during adolescence, highlighting the need for early identification and treatment. Read the NEJM Review Article here.
Q: Describe some of the epidemiological features of depression in adolescents.
A: Although the prevalence of depression has increased across all age groups, the increase among adolescents has outpaced that among adults. Depression can be familial, and the risk of depressive disorders extends across generations. In a multigenerational study, children with depressed parents and depressed grandparents had the highest rates of major depressive disorder. There is also evidence that parental depression negatively influences a young person’s response to treatment for anxiety and depression, and successful treatment of maternal depression is associated with a reduction in depression and improved functioning among young offspring.
Q: What features of depression are more common in adolescence than in adulthood?
A: Certain profiles of depression are more common in adolescence than in adulthood. Although depressed mood is the most common symptom in adolescents and adults with major depressive disorder, changes in appetite or weight, loss of energy, and insomnia are more common in adolescents, whereas anhedonia (loss of interest) and poor concentration are more common in adults. It is thus clinically important to ask adolescents about changes in sleep, energy, and appetite as part of the evaluation for depression.
A: Beyond encouraging the basics of mood hygiene, such as a regular daily schedule, good nutrition, and moderate levels of activity and exercise, pharmacologic intervention and psychotherapy are the mainstays of treatment for depression in adolescents. The selective serotonin-reuptake inhibitors (SSRIs) fluoxetine and escitalopram are approved by the Food and Drug Administration for the treatment of depression in adolescents, but other SSRIs and serotonin–norepinephrine reuptake inhibitors, such as venlafaxine, are commonly used off label for this purpose. The consensus in the field of adolescent depression has been to start treatment with an SSRI at a low dose, with a subsequent increase to a therapeutic dose, and to continue treatment for 6 to 8 weeks before assessing the response to the medication. The most extensively studied strategy for the approximately 40% of adolescents who do not have a response to an initial antidepressant trial is to switch to another SSRI rather than add another medication, an approach based on results from the Treatment of Resistant Depression in Adolescents study.
A: Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have been shown to be effective in treating depression in adolescents. Adolescents are taught to identify negative thoughts and reframe them as realistic thoughts, weighing the evidence that supports or negates them. IPT, which focuses on the relationship between depression and interpersonal interactions, reduces depressive symptoms while improving functioning by teaching patients to recognize their emotions and by working to improve interpersonal communication and problem-solving skills. A review of randomized, controlled trials of psychotherapy as compared with placebo or other active treatments showed the efficacy of CBT and IPT across independent research groups. Predictors of a poor response to psychotherapy across studies have included severe depression, low global functioning on assessment, high scores on suicidality measures, coexisting anxiety, distorted thought patterns, hopelessness, and family conflict.