Some helpful reminders on depression in children and young people. Maria Moldavsky Consultant Child and Adolescent Psychiatrist

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1 Some helpful reminders on depression in children and young people Maria Moldavsky Consultant Child and Adolescent Psychiatrist

2 The clinical picture What art and my patients taught me

3 Albert Durer ( ) Melancholia

4 Lucas Cranach ( ) Melancholy

5 Moretto da Brescia ( ) Portrait of a young man

6 The broad picture Is the low mood related to a physical illness? another mental health problem? substance use? family/social circumstances? Is the young person suicidal? psychotic? a risk to others/at risk from others?

7 Long-term factors Depression in CYP usually starts and is maintained for a reason However, we frequently get Nothing or I don t know as an answer CYP not aware of factors that play their role insidiously: early trauma lack of contact with one parent emotional needs not being met

8 Depression in YP with traits of an emergent Emotional Unstable PD Many different areas of difficulty, like a mosaic Poor sense of identity Changeable opinions about other people All areas of their life are chaotic Emotional dysregulation Psychotic symptoms but not clinically psychotic

9 Increasing degrees of suicidal risk There s no point in life I don t care what happens to me I wish I were dead I ll kill myself Making plans; setting a time Doing things to put the plans into action Being close to doing it Having tried

10 Beware of protective factors Family When in distress, young people think that they are a burden to their family they will be better off without me they will be upset for a while, then they will be fine Friends A disappointment or argument may increase suicidal risk Plans for the future Hopelessness makes YP think that they will never achieve them

11 Possible diagnoses What the international classifications taught me

12 Why is this important? It tells us all what questions to ask It helps you decide whether to refer to CAMHS what to include in your referral

13 ICD 10 diagnoses including symptoms of depression Depressive episode Recurrent depressive episode Persistent mood (affective) disorder Mixed disorder of conduct and emotions Adjustment disorder M&BD due to psychoactive substance use Organic mental disorder Schizoaffective disorder, depressive type

14 Depressive episode At least two of these symptoms: Depressed mood for 2 weeks, most of the day almost every day Loss of interest of pleasure in activities Decreased energy or increased fatigability Additional symptoms: Loss of confidence/self esteem Self-reproach/guilt Suicidal thoughts/ behaviour Less ability to concentrate/think Agitation/motor retardation

15 Depressive Episode: Diagnostic Criteria for Research Should last for at least 2 weeks No hypomanic or manic episode (lifetime) Episode not attributable to: Psychoactive substance use Organic mental disorder

16 Severity of Depressive Episode Mild: total of 4 symptoms With/without somatic syndrome Moderate: total of 6 symptoms With/without somatic syndrome Severe: all three main symptoms present; total of 8 symptoms With/without psychotic symptoms

17 Somatic syndrome At least four of these: Loss of interest/pleasure in activities Lack of emotional reactions Waking 2 hours before usual Depression worse in the morning Psychomotor retardation/agitation Loss of appetite Loss of weight: 5% in last month Loss of libido

18 Psychotic symptoms One of these: Delusions or hallucinations other than those typically schizophrenic Most frequent mood-congruent content: worthlessness, guilt, hypochondriacal, nihilistic Most frequent mood-incongruent content: selfreferential, persecutory Depressive stupor

19 Typically schizophrenic Delusions of control, influence or passivity clearly referred to body/limb movements or to thoughts/actions/perceptions Hallucinatory voices giving running commentary of patient s behaviour discussing the patient between themselves coming from some part of the body Persistent delusions that are culturally inappropriate and completely impossible

20 Persistent mood (affective) disorder: Dysthymia At least 2 years of constant depressed mood Periods of normal mood rarely longer than a few weeks Episodes not severe enough to be recurrent depressive episode At least 3 symptoms: Reduced energy Insomnia Loss of self-confidence Poor concentration Tearfulness Anhedonia Hopelessness Inability to cope Pessimism/brooding Social withdrawal Being less talkative

21 Adjustment Disorder Onset of symptoms occur within 1 month of exposure to a psychosocial stressor Affecting social network/wider system of social support Major developmental transition or crisis Individual vulnerability plays a role

22 Types of Adjustment Disorder Brief depressive reaction: mild depressive state, < 1 month Prolonged depressive reaction: mild depressive state, < 2 years Mixed anxiety and depressive reaction With predominant disturbance of other emotions; e.g. regressive behaviour in children of conduct; e.g. aggressive/dissocial behaviour in adolescents

23 Bereavement Normal bereavement reactions (<6months): No diagnosis; Z code Grief reactions considered to be abnormal because of their form, content or duration: diagnosed as Adjustment Disorder

24 DSM 5 Depressive Disorders A new diagnosis: Disruptive Mood Dysregulation Disorder (DMDD) Persistent irritability and frequent episodes of temper outbursts that are inconsistent with developmental level Symptoms present > 12 months, in at least 2 of 3 settings and are severe in at least one setting Onset before 10 years

25 Disruptive Mood Dysregulation Disorder Never had hypomanic or manic episode Symptoms do not only occur during an episode of major depressive disorder This diagnosis cannot coexist with Oppositional Defiant Disorder (DMDD overrides it) The term Bipolar Disorder is reserved for episodic presentations of irritability

26 Persistent Depressive Disorder (Dysthymia) In CYP: Irritability may be more obvious than low mood Only 1 year of low mood needed to make the diagnosis

27 How to treat depression in CYP What NICE and research taught me

28 NICE guideline Depression in CYP (Sept 2005): Risk factors for depression age gender family discord bullying physical, sexual or emotional abuse history of parental depression comorbid disorders, including drug and alcohol use homelessness refugee status living in institutional settings

29 Referral Management can remain at Tier 1 if: Exposure to a recent undesirable life event and: absence of other risk factors for depression Some risk factors (in the YP or family members) with no evidence of depression and/or self-harm in the YP mild depression without comorbidity

30 Criteria for referral to tier 2 or 3 CAMHS Depression with 2/more risk factors for depression Depression where 1/more family members (parents/children) have multiple risk factors Mild depression + no response to interventions in tier 1 after 2 3 months Moderate/severe depression (including psychotic depression) Recurrence of depression after recovery from moderate/severe depression Unexplained self-neglect >1 month Active suicidal ideas/plans Referral requested by YP/parent

31 Criteria for referral to tier 4 services High recurrent risk of acts of self-harm or suicide Significant ongoing self-neglect (e.g. poor personal hygiene or significant reduction in eating that could be harmful to physical health) Requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3

32 NICE: the stepped-care model Focus Action Responsibility Mild depression, incl. Dysthymia Moderate to severe depression Depression unresponsive to treatment/recurrent/ psychotic Watchful waiting Non-directive psychotherapy/group CBT/guided self-help Brief psychological therapy +/- Fluoxetine Intensive psychological therapy +/- Fluoxetine, Sertraline or Citalopram; augmentation with an antipsychotic Tier1 Tier 1 or 2 Tier 2 or 3 Tier 3 or 4

33 Main RCTs since 2005 The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. March et al, Arch Gen Psych 2007 A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial. Goodyer et al, Health Technol Assess 2008 Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes. Emslie et al, AM J Psychiatry 2010

34 USA The Treatment for Adolescents With Depression Study (TADS), 2007 N=327, age Mayor Depressive episode Compared CBT, Fluoxetine and their combination 36 weeks, 12 were blind

35 TADS: Conclusions In adolescents with moderate to severe depression, treatment with fluoxetine alone or in combination with CBT accelerates the response. Adding CBT to medication enhances the safety of medication. Combined treatment appears superior to either monotherapy as a treatment for major depression in adolescents.

36 The ADAPT trial, 2008 UK N=208, age Severely depressed Compared SSRI+CBT to SSRI alone 12 w treatment, 16 w maintenance No difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point

37 Treatment of Resistant Depression in USA Adolescents (TORDIA), 2010 N=334, age SSRI-resistant depression Compared medication switch alone with medication switch + CBT 24 w (non-responders had open treatment after 12 w)

38 TORDIA: conclusions Continued treatment for depression among treatment-resistant adolescents results in remission in approximately one-third of patients, similar to adults. Eventual remission is evident within the first 6 weeks in many, suggesting that earlier intervention among non-responders could be important.

39 Thank you very much for your attention Dr. Maria Moldavsky

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