ANXIETY AND DEPRESSION IN YOUTH Andrew Hall, MD, FRCP Child & Adolescent Psychiatrist MATC.

ANXIETY AND DEPRESSION IN YOUTH

Andrew Hall, MD, FRCP

Child & Adolescent Psychiatrist

MATC

All Truth is God’s Truth

Arthur Holmes(St. Augustine)

Nobody ever sees truth except in fragments

Henry Ward Beecher

Recognizing mental health disorders in Children & Adolescents can be difficult because they are experiencing so many changes already.

Changes in Behavior

Changes in Feelings

Changes in Physical Health

Changes in Thinking

Facts about Anxiety:

Anxiety Disorders are among the most common mental health problems to occur.

About 15 of every 100 children and adolescents ages 9 to 17 experience some kind of Anxiety Disorder.

Girls are affected more than boys. About 50% of children and adolescents with anxiety disorders have a 2nd anxiety disorder or other mental/behavioral disorder.

Anxiety Disorders may coexist with physical health conditions as well.

Why is this so important?Children & Adolescents

Median age of onset 11 – earliest of all forms of psychopathology

20% will have an Anxiety Disorder between the ages of 13 and 18

5.9% will have “severe” Anxiety Disorder

Only 18% of these teens receive treatment.

Fear, Anxiety, and Stress

Anxiety: Future-oriented worry of the unknown.

Fear: Present-oriented defensive response to observable threat.

Stress: Perceived environmental demands exceed one’s perceived ability to meet them.

3 Pillars of Anxiety

1. Fear of the unknown

2. Lack of control

3. Perception of danger

Brief Definitions

Anxiety is a general feeling of apprehension or worry and is a normal reaction to stressful situations

Red flags should go up when the feelings become excessive, thoughts become irrational and everyday functioning is debilitated.

Anxiety Disorders are characterized by excessive feelings of panic, fear or irrational discomfort in everyday situations.

When does Anxiety become disordered?

Distress

Avoidance

Interference

Functional Impairment

How Anxiety is Manifested

Youth may feel a sense of dread

Have fears of impending doom

Experience a sense of suffocation

Anticipation of unarticulated catastrophe

Loss of control over their breath, swallowing, speech, and coordination

Somatic complaints

What causes Anxiety Disorders?

Multiple, complex origins

Genetics

Stress Reactions (acute or chronic)

Learned Behavior (implicit or explicit)

Developmental factors

Childhood Fears and Worries

AGE FEARS

0-6 months Loss of support, loud noises

7-12 months Fear of strangers; fear of sudden, unexpected, and looming objects

3 years Masks, dark, animals, separation from parents

4 years Parent separation, animals, dark, noises (including at night)

5 years Animals, “bad” people, dark, separation from parents, bodily harm

6 years Supernatural beings (e.g. ghosts, witches, ghouls), bodily injuries, thunder and lightening, dark, sleeping or staying alone, separation from parent

7-8 years Supernatural beings, dark, fears based on media events, staying alone, bodily injury

9-11 years Tests and examinations in school, school performance, bodily injury, physical appearance, thunder and lightening, death, dark (low percentage)

Effects of Anxiety

School Failure Absenteeism Classroom disruption The inability to complete basic tasks Family Stress Impaired Social Relationships

Type of Anxiety Disorders

Generalized Anxiety Disorder (GAD)

GAD results in students experiencing six months or more of persistent, irrational and extreme worry, causing insomnia, headaches and irritability.

Post Traumatic Stress Disorder (PTSD)

PTSD can follow an exposure to a traumatic event such as natural disasters, sexual or physical assaults, or the death of a loved one. Three main symptoms: reliving of the traumatic event, avoidance behaviors and emotional numbing, and physiological arousal such as difficulty sleeping, irritability or poor concentration.

Panic Disorders:

Characterized by unpredictable panic attacks, which are episode of intense fear, physiological arousal, and escape behaviors. Common symptoms: heart palpitations, shortness of breath, dizziness and anxiety and these symptoms are often confused with those of a heart attack.

Specific Phobias:

Intense fear reaction to a specific object or situation (such as spiders, dogs, or heights) which often leads to avoidance behavior. The level of fear is usually inappropriate to the situation and is recognized by the suffered as being irrational.

Disorders continued…

Social PhobiaExtreme anxiety about being judged by others or behaving in a way

that might cause embarrassment or ridicule and may lead to avoidance behavior.

Separation Anxiety DisorderIntense anxiety associated with being away from caregivers, results

in youths clinging to parents or refusing to do daily activities such as going to school.

Obsessive Compulsive Disorder (OCD)Students ay be plagued by persistent, recurring thoughts

(obsessions) and engage in compulsive ritualistic behaviors in order to reduce the anxiety associated with these obsessions (e.g. constant hand washing).

Treatment Works!

Treatment success rates for Anxiety Disorders with CBT range from 60% to 90%.

Frequency, Intensity, Duration

Basic template for the Treatment of Anxiety Disorders in Youth

Assessment Psychoeducation

Cognitive Reappraisal Strategies

Exposure Parent Training

Relapse Prevention

Cognitive Behavioral Therapy

Principle of CBT is that thoughts influence behaviors and feelings, and vice versa.

Treatment targets patient’s thoughts and behaviors to improve his/her mood.

Essential elements of CBT include increasing pleasurable activities (behavioral activation), reducing negative thoughts (cognitive restructuring), and improving assertiveness and problem solving skills to reduce feelings of hopelessness.

The Cognitive Triangle

Relaxation Strategies

Deep Breathing Inhale for count of 5 and hold briefly Exhale for count of 5 Repeat 5 times

Progressive Muscle Relaxation• Begin with feet, contract muscles for count of

5 and slowly release.• Move up the body through all muscles groups

Things I can do to relax when upset(Identify ones that work for the youth)

Running Weight Lifting Going for a walk Playing a sport Listening to music Dancing Read Do a puzzle Crafts

Call a friend Talk to someone Take a hot shower Imagine a

relaxing place in my mind

Deep slow breathing

Check list of Cognitive Distortions:

1. All or Nothing thinking: You look at things in absolute, black-and-white categories

2. Overgeneralization: You view a negative event as a never-ending pattern of defeat.

3. Mental filter: You dwell on the negatives.

4. Discounting the positives: You insist that your accomplishments or positive qualities don’t count.

5. Jumping to Conclusions:

a: mind reading – you assume that people are reacting negatively to you when there’s no definite evidenceb: fortune-telling – you arbitrarily predict that things will turn out badly.

Cognitive Distortions continued…

6. Magnification or minimization: You blow things way of of proportion or you shrink their importance.

7. Emotional Reasoning: You reason from how you feel: “I feel like an idiot, so I must really be one”.

8. “Should Statements”: you criticize yourself (or other people) with “shoulds”, “oughts”, “musts” and “have to’s.”

9. Labeling: Instead of saying “ I made a mistake,” you tell yourself, “I’m a jerk,” or “a fool”, or “a loser”.

10. Personalization and blame: You blame yourself for something you weren’t entirely responsible for, or you blame other people and deny your role in the problem.

Other Considerations

Problem Solving

School Accommodations

Plan for Transitions

Reward and Praise the Youth’s efforts and successes

Encourage the Youth to participate in developing interventions.

School Accommodations to assist anxious youth:

Class participation Class presentations Answering questions at

the board Seating within classroom Testing conditions Lunchroom/Recess/

unstructured times Safe person Cool down pass

Large group activities/assemblies

Return after time away Field Trips Change in routine Substitute teachers Fire/Safety drill Homework

Expectations

Medication

When CBT/interventions don’t work…

Medication

Spectrum of Depression

Major Depression Disorder

Dysthymia

Adjustment Disorder with Depression

Adjustment Disorder with Mixed Anxiety and Depressed Mood

Bipolar Disorder

Substance – Induced Mood Disorder

Depression

2.5% children (M:F 1:1)

8.3% adolescents (M:F 1:2)

40-80% experience suicidal thoughts

35% of depressed youth will attempt suicide

Affects every facet of life – peers, family, school and general health.

How Depressive Symptoms manifest?

Mood Depressed or irritable mood Mood Lability

Behavior Kids may not verbalize sadness but show

low frustration tolerance, social withdrawal or somatic complaints

Decreased interest (stop sports etc.)

How Depressive Symptoms manifest continued…

Vegetative Symptoms Fatigue or decreased energy Sleep disturbance (often hypersomnia) Weight change, appetite change Decreased concentration or indecisiveness

Cognition Feelings of worthless/hopeless or

inappropriate guilt Thoughts of death or suicide

Criteria for Major Depressive Episode:Depressed mood or anhedonia + 4 others

S – sleep, insomnia or hypersomnia

I – interests

G – guilt, feeling worthless or hopeless E - energy C - concentration A - appetite P – psychomotor retardation or agitation S – suicidal thoughts or recurrent thoughts of

death

Symptom variation based on age

At all ages – depressed mood, “I don’t care”, bored, decreased concentration, insomnia and + SI

Children: >somatic complaints, separation anxiety, phobias , sad affect, auditory hallucinations

Teens: >anhedonia, hopelessness, drug abuse/self destructive behavior or atypical depression pattern Increased sleep, increased appetite and interpersonal

rejection sensitivity

Depression in Youth: timing of presentation

Susceptibility of developing brain

Sleep disturbances

Hormonal changes

Psychosocial pressures

Gathering History

Best to interview both parents and youth

Parents better at reporting behavioral disturbances and time course of symptoms

Youth better at reporting on mood/anxiety/sleep

Youth often have depressed mood or SI that parent is unaware of

Gathering History

R/O neglect, abuse physical or sexual Recent stressors Anxiety symptoms Unusual thoughts or psychotic

symptoms prodrome to Schizophrenia Symptoms of mania now or past –

decreased need for sleep, hypersexuality or grandiosity

FHx of suicides or Bipolar Disorder

Genetics

Depression runs in families Monozygotic twin 76% concordance; and

if raised separately 67% concordance Children with one depressed parent are

3x more likely to have MDD than children of non-depressed parents

Need to ask about family history of Bipolar Disorder or any Mood Disorder

Effects of depressed parents

Depression in parents associated with child depression (mothers>fathers).

Depressed children tend to have poor relationships (family and friends) & often have depressed parents.

Depressed parents may over-report concerns (focus on negative aspects) or under-report (too depressed to attend to or observe child accurately.

Differential

Mononucleosis TB Hepatitis Subacute

endocarditis

Epilepsy CVA Multiple sclerosis Post concussive

states Subarachnoid

hemorrhage

Infectious Neurologic

Differential continued…

Diabetes Cushing’s disease Addison’s disease Increase or decrease

thyroid Increase parathyroid Decrease pituitary

function

Lupus Porphyria Anemia Etoh or drug abuse

Endocrine Others

Workup

History

Physical exam

CBC, electrolytes, LFT’s, TSH, UA and B12, vit D

Consider Urine Drug Screen

Course of Major Depression

Median duration of Depression episode is 8 months

70% of pts have a recurrent MDE within 5 years

Course of Major Depression

Early age onset Increase in number of

previous episodes Severity Psychosis Lack of compliance

Increased symptom severity

Chronicity of Increased number of relapses

Residual symptoms Negative cognitive

style or hopelessness Family problems Ongoing negative life

events

Prediction of relapse Poor prognosis

Sequelae

Depression untreated affects social, emotional, cognitive and interpersonal skills

Any episode 7-9 months is a long time in a youth’s life

High risk for nicotine & substance dependence, early teen pregnancy, physical illness

As adults, higher suicide rates, more medical & psychiatric hospitalization, more impairment in work, family and social life.

Treatment

Psychoeducation Parents School

Individual psychotherapy Supportive Cognitive Behavioral Therapy Interpersonal Psychotherapy

Family Therapy Medication

Psychoeducation

All patients should receive Information about symptoms and typical course

with discussion (depression is an illness; not a sign of weakness; no one’s fault etc.)

Discussion of treatment options Placing pt in sick role temporarily may be helpful

and temporary school accommodations

No controlled trials with just psychoeducation, however, many pts improve with only education and supportive care.

Supportive Treatment

All patients should receive and may be all that is required for mild depressive sx’s Meeting frequently to monitor progress Active listening and reflection Restoration of hope Problem solving Improving coping skills Behavior activation

If not improving in 4 weeks, move to a more specific treatment

Treatment Options

If has moderate to severe depression, start with more specific treatment OR if mild to moderate depression not improving after 4 weeks of supportive care (watchful waiting):

Individual psychotherapy Cognitive Behavioral Therapy Interpersonal Psychotherapy

Family therapy Medication

Severe Depression – start meds and other referrals

Cognitive Behavioral Therapy

Principle of CBT is that thoughts influence behaviors and feelings, and vice versa.

Treatment targets patient’s thoughts and behaviors to improve his/her mood.

Essential elements of CBT include increasing pleasurable activities (behavioral activation), reducing negative thoughts (cognitive restructuring), and improving assertiveness and problem solving skills to reduce feelings of hopelessness.

Interpersonal Therapy

Principle of IPT is that interpersonal problems may cause or exacerbate depression and that Depressions, in turn, may exacerbate interpersonal problems.

Treatment will target patients' interpersonal problems to improve both interpersonal functioning and his/her mood

Essential elements of ITP include identifying an interpersonal problem area, improving interpersonal problem solving skills, and modifying communication problems.

Medication Treatment Options

Selective Serotonin Reuptake Inhibitors Selective NE Reuptake Inhibitors Other antidepressants Tricyclic Antidepressants

Typical duration of medication treatment 6-12 months after response present.

Relapse high if stopped within 4 months of symptom improvement.

Medication - SSRIs

*Fluoxetine (Prozac) – age 8 Sertraline (Zoloft) Paroxetine (Praxil) Citalopram (Celexa) *Escitalopram (Lexapro) – age 12 Fluvoxamine (Luvox)

*FDA approved for the treatment of MDD under age 18

Medications - SSRIs

Early studies – struggled with high placebo response rates, had to redesign to screen and have a waiting period to find subjects that did not respond to psychoeducation and supportive care

Emslie (1997) – 1st study showing SSRI efficacy for adolescent depression (fluoxetine) 58% fluoxetine response rate vs. 32% placebo

Emslie (2002) – 2nd study N= 219 pts RCT received 20 mg fluoxetine vs. placebo for 8 weeks 41% remission fluoxetine vs. 20% placebo

SSRIs - dosing

Typically once a day dosing in adults/teens Morning for fluoxetine & sertraline Evening for paroxetine, citalopram &

escitalopram

Pre-pubertal children metabolize more quickly – may need twice daily dosing

Ensure an adequate trial before changing meds, maximum tolerated dose for at least 4-6 weeks.

SSRIs – Common Side Effects

Nausea and diarrhea – 5HT receptors numerous in gut, need to titrate slowly, this side effect remits with exposure.

Headache – usually remits with time

Agitation, impulsivity or activation – 3-8% pts

Insomnia

Fatigue or sedation (more common with paroxetine, citalopram or escitalopram)

SSRIs – predicting remission

50-60% of patients get response with 1st SSRI

30% of patients get into remission with 1st medication trial

Predictors of remission include +FHx of depression Early symptom response (within 4 weeks)

Treatment of Adolescents with Depression (TADS)

Follow up 5 years later N=196 pts (44.6% of original cohort)

By 2 years, 96.4% had achieved recovery Predicted by early response to meds

By 5 years, 46.6% a recurrence

Medication Summary

Most evidence for SSRIs

Meds considered first line Fluoxetine (Prozac) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro)

Treat for 6-9 months once symptoms have improved

Goal to treat to remission (no sx’s for >2 months)

Suicide

CDC – 17% of adolescents think about suicide each year

Thoughts of death are part of MDD

3rd leading cause of death in adolescents about 2,000 deaths per year

25% decline in suicide rate in 10-19 year range in past decade

Suicide attempts often impulsive in nature

FDA warning about +SI and antidepressant meds

FDA reviewed 23 studies with 9 different meds - >4,300 youth

NO SUICIDES in these studies

Adverse events reporting – SI or potentially dangerous behavior reported by 4% of pts on meds vs. 2% on placebo

17 of 23 studies asked about SI – no new SI or worsening of SI, actually decreased during treatment

Suicide and SSRIs

FDA changed black box warning from specific monitoring to more general one

All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increase or decreases.

General advice for families regarding SI

No firearms in home Limit access to medication including over the

counter meds Remove access to parent’s medications Remove razors from bathroom or other sharps Increase supervision (e.g. keep doors open, limit

peer contact to with adults present) Importance of seeking help if suicidal thoughts

develop or worsen Mobile Crisis team, Children’s Hospital E.R. and 911

The ABCs of Mental Health

Teen Mental Health

Canadian Mental Health

Kidshealth.org

Keltymentalhealth.ca

StressHacks.ca

Thank you! Questions?