Health risk behaviors, including substance abuse and risky sexual behavior, contribute to the major causes of morbidity and mortality in adolescents in the United States. Approximately 74% of deaths adolescents and young adults in the US were the result of four main causes: motor vehicle collisions, unintentional injuries, suicide, and homicide.1 It is reasonable to believe that many if not most of these deaths were avoidable. Therefore, addressing the risky behaviors and the factors that promote the development of health risk behaviors would be a logical approach to decreasing the burden of these major contributors to death in the adolescent population. The Youth Risk Behavior Surveillance System (YRBSS)1 monitors six categories of behaviors that could be considered as risky and can contribute to the development of depressive disorders. These include behaviors that contribute to unintentional injuries or violence (which may be related to impulsivity and risk-taking), tobacco, alcohol and other drug use, risky sexual behaviors, and unhealthy dietary/physical behaviors and inactivity.
Epidemiology and Risk Factors for the Development of Depression in Adolescents
Depression is possibly the most important risk factor for suicide and thus makes itself an appealing target for resources to address this major cause of morbidity and mortality in adolescents. In studies evaluating completed suicides, more than one-half of the patients studied had previously been diagnosed with depression.2 In another study, nearly 30% of patients with major depressive disorder (MDD) reported suicidal ideations in the preceding 12 months, with nearly 12% of adolescents with depression having attempted suicide.3 Furthermore, as it relates to adolescent depression and morbidity and mortality, patients with a history of substance abuse were more likely to exhibit depressive symptoms.2 The sequelae of high-risk sexual behavior may include unwanted pregnancies and decreased attainment of educational goals, which in turn may affect an adolescent's “coping reserve” to deal with future stressors.
For many, the adolescent years signal a time of change, characterized by educational and psychosocial development. Throughout adolescence, a rising prevalence of depression is noted and appears particularly pervasive in female adolescents.4 Compared to their male adolescent counterparts, adolescent females were 4 times more likely to have severe MDD; in a survey of more than 9,000 adolescents between grades 6 and 10, 20% of girls reported depression compared to 10% of boys.3 Significant and severe life events among several domains has shown to be associated with the development of depression in both adults and adolescents: adolescents with depression are at least twice as likely to have endured more severe stressful events.5 One significant difference between adolescents and adults was that, in adolescents, significant life events occurring in close contacts such as parents, grandparents, siblings, and friends, also appeared to affect development of depression.5 Adolescents may internalize the life events of their close peers and family members into their own depression-developing experience, as well as their own life events.
The next stressful event that can affect depression is bullying. Physicians should assess for bullying history in adolescent patients. Youths involved with bullying, either as victims or perpetrator, were twice as likely to have symptoms of depression.4 Nearly 1 in 5 adolescents surveyed in the large YRBSS reported being bullied on school property in the preceding 12 months.1 Patients with depression were more likely to be involve with physical fights at school.4 Victims of bullying with depression may be an easy target as they demonstrate social withdrawal from their peers and thus have poor protective connections to the larger “herd.” Furthermore, the depressed perpetrators of the bullying may themselves be victims of neglect and abuse in their home life. Their bullying behavior may be an externalizing component to their psychosocial distress.
Socioeconomic factors contributing to the development of depression have yielded mixed results across various studies and may ultimately suggest that other factors related to these socioeconomic factors may play a role in identification of depressive symptoms in adolescents. For instance, non–English-speaking patients and Hispanic families in one review were found to be less likely to have the benefit of continuity with a primary care provider.6 This may limit detection or cause underrecognition of mood issues, especially if the care provided is brief or not focused on behavioral health issues.
Patients with chronic medical conditions were more likely to endorse depression symptoms. The chronic medical conditions most associated with depression symptoms included asthma, allergies, back pain, and anemia.7 Recent studies have also explored and suggested increased risk for depression among those who have been diagnosed with concussions.8 Other studies revealed that patients with asthma and diabetes were also more likely to be diagnosed with mood disorders.9,10
Maternal and parental factors are emerging as important contributors to the development of depression in adolescents. Maternal depression has been associated with adolescent depression. Early parental loss as well as parental psychiatric comorbidities have also been associated with major depressive disorder during childhood.10 The contribution is likely to be a unique combination of both environmental and genetic factors, as the genetic propensity to develop depression may be coupled with impaired parent-child bonding, and possibly neglect and abuse. The individual contribution of these risk factors may not be easy to separate as even children and adolescents in foster care and various stages of the adoption process have higher rates of depressive disorders, which may further confound attempts to distinguish the genetic from the environmental factors in the development of depression.2
Patients who have reported depressive symptoms, even when the symptoms did not yield a diagnosis of MDD, are at higher risk of developing depression in the near future.11 The trajectory of depressive symptoms was associated with impairment in educational attainment and social functioning. This raises questions regarding the impact of subthreshold or mild depression in adolescent psychosocial development, as prepubertal children reporting depressive symptoms were more likely to develop a depressive disorder as adolescents.12 Therefore, patients who have been identified as having depression symptoms, even without an MDD diagnosis, may benefit from routine assessment of depressive symptoms to identify the onset of MDD in this group. One study evaluating the presentation of major depression in children and adolescents suggested that although nearly 1 of 3 children and adolescents appeared to develop depression acutely without prior suggestion of mood disorders, nearly one-half of patients studied had an “oscillating or insidious course” over the preceding 24 months prior to diagnosis with MDD.13 An oscillating course can be characterized by symptomatology including irritability, anger, and mood swings, rather than the typical depressed mood expected in adult presentations.
By studying and understanding the factors involved in the development of depression in adolescents, we may improve the identification and assessment of youth who are at risk at the initial points of contact with adolescents. And although (surprisingly) there have been no large studies to suggest that screening adolescents for depression in the primary care setting has led to improved outcomes in the short or long term, there is reason to believe that improving identification rates, as well as rates of assessment and management for depression in this population is a step in the right direction.
Conditions Comorbid with Depression in Adolescents
Two-thirds of adolescents with depression have at least one comorbid condition.14 Patients with comorbidities have poorer long-term outcomes and more severe impairment than those with depressive symptoms only, and depression co-occurs with addictive disorders, trauma-related disorders, and anxiety, as well as developmental delays and personality disorders. When thinking of comorbidities, a network perspective might be helpful, as some factors can be proximal to the development of depression whereas some can occur as a result.15
Concurrent comorbidity with both disruptive and emotional/mental disorders is common in the adolescent population. In a study of adolescents with depression conducted in Germany, 62.5% had at least one comorbid psychiatric diagnosis, with anxiety and emotional disorders (23.7%), somatoform disorders (16.8%), hyperkinetic disorders (16.2%), and posttraumatic stress disorder (10%) being the most frequently diagnosed.16 The risk of comorbidity increases with age; for example, whereas 7% of children with autism spectrum disorder were estimated to carry a diagnosis of depression, the rate was only 4.8% children age 6 to 12 years, but was 20.2% in those age 13 to 17 years.17 Adolescents with depression are about 6 to 12 times more likely to have disruptive behavior issues as well.18
Depression may precede substance use disorders or may develop as a consequence of preexisting substance use disorders. One study found that from 1993 to 2003, the number of adolescents presenting to publicly funded substance abuse treatment facilities increased 61%, and the prevalence of depressive disorders in these patients increased from 24% to 50%.19
Depression is much less likely to remit with substance abstinence in adolescents than in adults with depression with comorbid chronic alcohol or drug dependence. Recent controlled trials indicate that treatment of comorbid psychiatric disorders alone is not likely to significantly reduce substance use or induce abstinence in dually diagnosed adolescent.20 Current research supports integrating the treatment of co-occurring psychiatric disorders with treatment for drug abuse.20
Adolescence is a critical time for brain and social development, but it is also the time during which most mental disorders reveal themselves. It is estimated that up to 75% of mental illness starts in adolescence.10,21 The development of mental illness relates to lower educational attainment, lower graduation rates from high school and college, lower likelihood of being employed as an adult, and a higher likelihood of developing chronic physical illnesses in all countries surveyed by the World Health Organization National Mental Health Survey.22
The clinician faces a challenging task of correctly identifying the symptoms at hand and selecting effective treatments. The first challenge in treatment of adolescents includes the fact that symptoms for depression and anxiety can be vague and nonspecific. Clinical features, family history, and careful assessments can assist in distinguishing and predicting trajectories, but the clinical staging and detection of clinical antecedents remains difficult despite an impressive body of research.23 The development of depression is associated with decreased brain cortical thickness24 that can potentially modify a person's life and achievement trajectory permanently.
Depressive symptoms (not necessarily meeting the criteria for major depressive disorder) can represent prodromal psychosis and predate the development of psychotic disorders. To complicate matters, cannabis use is also associated with the prodromal phase of psychosis and is highly comorbid with depressive disorders.25 In a meta-analysis of more than 23,000 adolescents and young adults, cannabis use was associated with increased odds of depression (1.3) and suicide attempts (almost 3-fold increase).26 In cases of severe trauma, both depression and psychosis symptoms can be present. The presence of atypical symptoms, such as anergia and hypersomnia, can raise suspicion of prodromal psychosis, whereas atypical responses to antidepressant treatments may hint at bipolar affective disorders. One widely publicized and scrutinized effect of antidepressant treatment—development of suicidal ideations—could in fact be linked to a misdiagnosis of bipolar affective disorder in youth and subsyndromal manic or hypomanic episodes.27
Studies such as the Treatment for Adolescents with Depression Study (TADS)28 and Treatment of Resistant Depression in Adolescents (TORDIA)29 have demonstrated that antidepressant medications are effective in treating depression in the pediatric population. However, only two antidepressants are approved by the US Food and Drug Administration (FDA) to treat pediatric depression: fluoxetine and escitalopram. Consequently, most of the medications used to treat depression in youth are considered off-label.
When deciding how to treat depression in youth, it has been shown that mild depressive episodes can be treated effectively with psychotherapy.30–32 However, moderate to severe depressive episodes benefit from pharmacotherapy.28,29 Studies also suggest higher efficacy of treatment when an antidepressant is combined with psychotherapy, particularly cognitive-behavioral therapy (CBT);29,30 secondary analysis of the TADS data highlights that combining pharmacological management with psychotherapy helps with symptom improvement and expanding the range of populations that benefit from intervention.33 Further study is needed to assess the effectiveness of different types of therapy for pediatric patients with depression.
Although fluoxetine and escitalopram are the only two antidepressants approved by the FDA for use in adolescents, there have been positive studies supporting the effectiveness and use of sertraline34 and citalopram35 in youth with depression. Other antidepressants to consider include selective norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine.36,37 However, current data do not support use of SNRIs as primary treatment for pediatric depression, and no antidepressant has consistently demonstrated positive results for depression in prepubertal children.38 Paradoxical development of suicidal ideations is a significant, yet infrequent, risk in adolescents treated with antidepressants. There are no established cardiac, blood pressure, or cardiac-related adverse effects of therapeutic doses of nontricyclic antidepressants.39 Thus, research has clearly highlighted the that the benefit of treatment outweighs the risks.
In the event of treatment-resistant depression, it is recommended to try a different selective serotonin reuptake inhibitor if the first trial is ineffective.29 If partial response is obtained with the second trial, then augmentation might be considered, although there is no evidence for specific agents. Once symptom remission is achieved, treatment should continue for 6 to 12 months before taper is initiated.
Psychotherapy for Depression in Adolescents
As mentioned above, there has been limited research into what types of psychotherapy are most effective for depression in youth. CBT has been proven effective,32 but studies also indicate that child-centered therapy may not be as beneficial as family-based interventions.40 This is best explained perhaps in terms of the child being embedded in the family network and not independent, so improving the family environment and/or equipping the family with better tools to cope with depression can have far-reaching effects. Family-focused treatment (15 sessions) was shown to be superior to individual supportive psychotherapy in children age 7 to 14 years.41 Manualized interventions based on family system theory, such as Behaviour Exchange Systems Training for adolescent depression, have shown promise42 in reducing depressive symptoms in adolescents, as well as reducing depressive symptoms in parents (even those with no full diagnosis of depression).43 Resurging interest in psychodynamic therapy has led to more evidence-based effort in that realm, including the First Experimental Study of Transference Work–In Teenagers.44 Group therapy for adolescents also has preliminary effectiveness data.45
The Improving Mood with Psychoanalytic and Cognitive Therapies study, comparing three types of psychotherapy in adolescents, is pending results at this point, but predictors for dropout from treatment (a negative prognostic sign) include age (older adolescents more likely to drop out), low verbal intelligence, antisocial traits, and low therapeutic alliance scores.46
An interesting trend in treatment of children and adolescents with depressive symptoms is that psychotherapeutic interventions were used more often when patients had co-occurring diagnoses, such as posttraumatic stress disorders.47
Modular treatment, combining pharmacological treatment, psychotherapy, and behavior training for conduct issues, was found to be more effective than standard treatment, highlighting again the importance of integrative, flexible treatment for this age group.48 Modular approaches include the Modular Approach to Therapy for Children,48 which focuses on four areas: anxiety, depression, conduct, and traumatic stress. The protocol consists of 33 modules but allows for adaptation, taking crises into consideration. It also includes parent-management training procedures. The child System Treatment and Enhancement Projects program, which includes transdiagnostic considerations (behavior and symptom focus, not only diagnosis focus) and weekly feedback, which is now being tested in various countries, has shown consistent success.49
Psychoeducational interventions, in the form of family, group, or individual programs, target identification of depressive symptoms, education about such symptoms, encouragement to link to treatment, and self-help skills, all of which can be helpful. Interventions were used mostly as adjunctive treatments, with few being used as first-line treatments, and could be applied to people with depression or to people deemed at risk. Adolescents can be taught how to better problem-solve, cope, and resolve conflict, as well as being taught relaxation techniques. Resources for stress exposure can also be provided.
In a review of 79 studies, methodology for psycho-educational interventions was not uniform and a variety of methods were adopted: printed, online, game, or lectures/educational groups.50 Electronic delivery of health interventions for anxiety or depression in children and adolescents with chronic physical conditions is a budding field, and in a meta-analysis some effectiveness is suggested but firm evidence is lacking.51 Given that most adolescents use mobile phones extensively, there has been much interest in smartphone apps for mental health conditions, even for children without physical conditions; smartphone app acceptability was found to be good, but most apps did not undergo rigorous research evaluations.52
Depression in adolescents can carry heavy, potentially lifelong morbidity but responds to various treatment modalities. Many exciting prospects, such as electronic/mobile health delivery, a focus on pharmacological augmentation measures, and more research into clinical staging and early interventions are promising future paths for treatment.
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