Adolescent Health Care: A Practical Guide

Chapter 78

Adolescent Depression and Anxiety Disorders

Stan Kutcher

Sonia Chehil

Depression and anxiety disorders are common psychiatric disorders during adolescence. According to the World Health Organization, these disorders contribute the largest single burden of disease in young people (World Health Organization, 2003). Depression and anxiety disorders may occur concurrently or separately. Individually, each disorder is often accompanied by symptoms of the other and both are often preceded by impairing anxiety symptoms that start in childhood. Childhood anxiety is in fact one of the best predictors of depression later in life. Early diagnosis and effective interventions can enhance the short- and long-term functioning and prevent or significantly modify the characteristic lifelong chronic nature of these illnesses.

Depression

Depression, as a clinical entity, is the prolonged presence of persistent low mood, negative cognition, and withdrawn behavior that leads to significant functional difficulties in many aspects of life (social, interpersonal, family, educational, and vocational). It must be differentiated from the usual, expected, and relatively transient mood difficulties that most individuals experience in the course of their daily living, which in popular parlance is also called depression, as well as from a state of “demoralization,” which is a more prolonged mood disturbance, usually resulting from ongoing negative life experiences. The importance of differentiating “normal” transient low mood states and demoralization phenomenon from clinical depression in adolescents may be difficult. Mood states during the teen years may fluctuate rapidly and may be expressed in a variety of different affective, cognitive, and behavioral dimensions, some of which, if not critically considered, may be mistaken for symptoms of a clinical depression. For example, the teen who emphatically states, “I am so depressed that I can not stand it”; or the teen who thinks “now that my boyfriend has left me I can't go on with life”; or the teen who locks himself in his room for a couple of days because he was removed from the basketball team, may not be depressed at all, but just be demonstrating the expected enhanced emotionality of the adolescent years. Careful diagnostic assessment is necessary to avoid overdiagnosis and subsequent exposure to unnecessary treatment or underdiagnosis and subsequent denial of needed treatment. In the clinical situation, it may take two or more visits and an independent perspective (such as that of the parents) before the clinician is able to determine the presence or absence of a depressive syndrome with a high degree of certainty (Table 78.1).

Epidemiology

1. Self-reported symptoms of depression are very common in normal adolescent populations. In studies of adolescents in the United States, up to 50% of teens report feeling depressed within the 6-month period before the questioning with significant numbers (up to approximately 20%) reporting suicidal ideation. When Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are applied, studies show that approximately 5% to 8% of teens will qualify for the diagnosis of major depressive disorder (MDD) (perhaps slightly fewer if strict functional disability criteria are stringently applied).
2. In the 2005 Youth Risk Behavior Surveillance (Centers for Disease Control and Prevention, 2006), 28.5% of high school students reported feeling sad or hopeless almost everyday for over 2 weeks in a row during the last year. This rate was 36.7% in females and 20.5% in males. Rates were highest in Hispanic high school students—36.7% compared to black (28.4%) and white (25.8%).
3. Rates by age: The rates range from approximately 1% prepubertally to near adult rates (8%–10%) by the end of the teen years.
4. Gender: Girls are approximately twice as likely to demonstrate clinical depression as boys.

These data illustrate the importance of differentiating depressive symptoms from clinical depression (Kessler et al., 2001; Birmaher et al., 1996a,b).

Suicide

Trends in suicide rates across the lifespan tend to parallel those of depression with low suicide rates reported prepubertally followed by a rapid rise in suicide rates over the adolescent years, peaking in early adulthood and remaining relatively level until the geriatric phase of the life cycle. In the United States, adolescent suicide is consistently amongst the top three causes of mortality in this age-group. It is highly correlated with unidentified

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and untreated depression. Although suicide rates in adolescents have increased over the period 1950 to 1990, the last decade has seen a significant decrease in suicide rates in the United States. Although the reasons for this are not clear and the cause is likely to be multifactorial, there is a strong association between this decrease in suicide and an increase in the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of adolescent depression (Simon et al., 2006; Olfson et al., 2003; American Academy of Pediatrics, Committee on Adolescence, 2000). See Tables 79.3 and 79.4 for suicide rates in high school students from the Youth Risk Behavior Survey. Any adolescent complaining of suicidal intent or who has made a suicide attempt must be evaluated carefully for the presence of a depressive disorder (DD).

TABLE 78.1 Distinguishing Clinical Depression from Common “Similar” Conditions

Condition Description ADHD, attention-deficit hyperactivity disorder; DSM, Diagnostic and Statistical Manual of Mental Disorders; MDD, major depressive disorder. Depression (symptoms) Usually transient mood, behavioral, and somatic symptoms. Often associated with negative life events. Does not cause significant functional impairment. This is not a psychiatric disorder, does not require medical intervention. Demoralization Mood, behavioral, and somatic symptoms may be relatively long standing but clearly related to external situation and would resolve if the situation resolves, does not cause significant functional impairment. May be secondary to effects of another mental disorder (such as the demoralization experienced by teenagers with ADHD who have difficulties with schoolwork and who may fail subjects as a result). This is not a psychiatric disorder and does not require medical intervention although if secondary to another mental disorder should be addressed within the context of the treatment of the other illness. Depression (as a clinical syndrome) Includes the DSM diagnostic categories of MDD and dysthymic disorder. Meets severity and duration criteria for one of the DSM categories and must include significant functional impairment. This is a psychiatric disorder and medical treatment is indicated—either pharmacological or psychological or both.

Risk Factors for Adolescent Depression

A multitude of “risk factors” have been identified for adolescent depression. However, it has been difficult to separate risk factors which are highly predictive (causal) from associated factors.

• Highly predictive risk factors: Their presence usually foreshadows the onset of adolescent depression in the future.
• Associated risk factors: Factors that often occur concurrently with adolescent depression but are not necessarily predictive of future onset of adolescent depression.

Highly Predictive Risk Factors

1. Maternal history of MDD
2. Previous episode of MDD

Associated Risk Factors

1. Family conflict with poor affective involvement and significant communication difficulties
2. Exposure to significant negative life events

In “real life” cases it may be difficult to determine the nature of the risk factors identified.

For example, a depressed teen may have a depressed parent and also live in a family where conflict and poor affective support exist. It is hard to determine if the causal factor is the genetic risk passed on through the depressed parent or the environment which itself may be the result of parental depression, or both.

In addition, studies are just now beginning to help differentiate proximal versus distal risk factors.

• Proximal risk factors: Those occurring immediately or shortly before the onset of the event—in this case an episode of depression.
• Distal risk factors: Those occurring at some point in time before the onset of the event—in this case depression.

Proximal Risk Factors

1. Anxiety disorder such as panic disorder (PD), social anxiety disorder (SAD), and so on
2. Medical condition such as diabetes or cancer

If the clinician is aware that the teenager has a positive family history of MDD or bipolar disorder, “preventive counseling” in the prepubertal period may help the parent and teen identify significant mood disturbances should they arise. If such mood disturbances are identified, the parent and teen will to be better prepared to seek clinical attention early.

Distal Risk Factors

1. Family history of MDD or bipolar disorder (especially the female children of a mother who has had a clear episode of MDD)
2. Early prolonged abuse (sexual or physical)
3. Early death of a parent

Negative Life Events

Negative life events are commonly but often mistakenly considered to be causal risk factors for adolescent depression.

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These events include but are not limited to breakup of a romantic relationship, school problems, geographic moves, or family difficulties. The reality is that these life events are so common among adolescents that if they were causal, every teenager would be clinically depressed. These events however may lead to distress, depressive symptoms, and even demoralization but are not likely to be single substantive causal factors for MDD. Another difficulty in exploring the impact of negative life events on MDD is understanding the timing of the onset of depression in adolescents. Typically, DDs are not known to have a sudden onset; instead, they have a gradual and insidious onset. In fact, the onset is often so gradual, that the associated dysfunction can be overlooked. It is not uncommon for the gradual onset of the DD (and not yet identified) to lead to significant life events such as interpersonal problems, family difficulties, romantic breakups, and a variety of school difficulties. Following these events, the depression may become more clearly manifest. Therefore, events which may be identified as “causal” for a depressive episode may actually be the result of the episode itself.

Diagnosis

The diagnosis of depression is made using DSM-IV-TR criteria (American Psychiatric Association, 2000) or the International Classification of Diseases (ICD) criteria (World Health Organization, 1992). In the United States, the DSM criteria are most commonly used. The DSM classifies three types of DDs:

1. MDD
2. Dysthymic disorder
3. Depressive disorder not otherwise specified (DD-NOS)

There is good consensus about the diagnostic categories of MDD and Dysthymic disorder. There is less consensus about the category of DD-NOS. In the opinion of the authors of this chapter, the DD-NOS diagnosis should not be used to justify medical interventions in this age-group.

DSM Criteria for MDD

In order to meet DSM criteria for MDD, the young person must have experienced one or more major depressive episodes (MDEs) without ever having experienced a manic, mixed, or hypomanic episode.

Diagnostic Criteria for a Major Depressive Episode (Adapted from DSM-IV-TR)

For at least 2 consecutive weeks the adolescent has experienced five (or more) of the following symptoms which represent a change from previous functioning; one of the symptoms must be either depressed or irritable mood or markedly diminished interest or pleasure.

1. Depressed or irritable mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all or almost all activities nearly every day.
3. Significant weight loss when not dieting or a weight gain of >5% of body weight in a month ora decrease/increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (this symptom mustbe noticeable to others and not merely subjective feelings).
6. Fatigue or loss of energy nearly every day.
7. Feeling of worthlessness or excessive/inappropriate guilt nearly every day (this does notinclude self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness nearly every day.
9. Recurrent thoughts of death, recurrent suicidal ideation, a suicide attempt, or a specific plan for committing suicide.

In addition to the symptom complex described earlier, the following must also be present:

• The symptoms cause clinically significantdistress or impairment in social, occupational, or other important areas of functioning.
• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
• The symptoms are not better accounted for by bereavement.

If all of the aforementioned conditions are not met, then the adolescent does not meet the diagnosis for a MDE.

Some youth may experience long-standing and persistent depressive symptoms that are not demoralizing and cause functional difficulties. These youth may be demonstrating DD which is a chronic mood disturbance characterized by depressive symptoms that are present most days for at least a period of 1 year.

Diagnosis of Dysthymic Disorder (Adapted from DSM-IV-TR)

1. Depressed or irritable mood for most of the day, for most days for at least 1 year.
2. Two or more of the following must be present:
3. Poor appetite or overeating
4. Insomnia or hypersomnia
5. Low energy or fatigue
6. Low self-esteem
7. Poor concentration or difficulty making decisions
8. Feelings of hopelessness

In neither MDD nor Dysthymic disorder can the symptoms be part of a schizophrenic, schizoaffective, bipolar, or delusional illness. The two DDs described here may have a seasonal component. It is important to note that should there be a seasonal component present this does not affect diagnosis or treatment of the disorder.

Identifying the Depressed Adolescent

Underrecognition of clinical depression in teens is common in primary care (Asarnow et al., 2002; Rushton et al., 2002). This may be in part due to the different clinical presentation of depression in teens as compared to adults (youth may present with marked irritability rather than sad or depressed mood) and may be compounded by the hesitance of teens to self disclose symptoms of depression if not asked directly about these symptoms during a clinical assessment.

Screening Tests

It is reasonable for clinicians to screen for depression, because it is one of the most common medical disorders that begin in the teenage years. Screening tests include the Kutcher Adolescent Depression Scale, the KADS-11

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(an 11-item version of the KADS self-report questionnaire), the Beck Depression Inventory (Beck and Steer, 1987), the Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1987), and the Mood and Feelings Questionnaire (Thapar and McGuffin, 1998). Most of these take longer to administer than the six-item KADS and their sensitivities and specificities range from 0.70 to 0.90 and 0.39 to 0.90, respectively.

Some general health screening tools for adolescents have been studied in primary care. These include the Patient Health Questionnaire for Adolescents (Johnston et al., 2002) and the Safe Times Questionnaire (Schubiner et al., 1994). Screening tools in the primary care setting is strongly recommended, as the evidence suggests that sole reliance on a teenager's reporting of depression as a chief complaint may miss a significant number of depressed youth (Zuckerbrot and Jensen, 2006).

1. The KADS(six-item version) (Fig. 78.1) has been validated as a screening tool for depression in adolescents (LeBlanc et al., 2002; Brooks, 2004; Brooks et al., 2003). One study found that in a population of students in the 7th to 12th grade, the brief instrument was as good as the Beck Depression Inventory and better than the 16-item KADS in its overall diagnostic ability, with sensitivity of 92% and a specificity of 71% at a cutoff score of 6 (LeBlanc et al., 2002). A distinct advantage of the six-item KADS is its brevity and the ability to combine it with other brief tools in the screening of mental illnesses. It is a brief self-report questionnaire, which the teenager can fill out while waiting for an appointment. It can also be used to screen large numbers of adolescents (such as a secondary school population) if a public health framework is being considered. A score of 6 or higher (or a score of 2 or higher on question six) should lead to a careful clinical assessment directed at determining the presence or absence of a depressive syndrome (clinical depression).
2. An 11-item version of the KADS self-report questionnaire (KADS-11)is ideal for assessment and monitoring purposes in clinical settings (Fig. 78.2). The items on the KADS-11 are worded using standard and colloquial terminology, and responses are scored on a simple 4-point scale. Once the youth has completed the KADS-11, clinicians can review and discuss the individual items of the KADS with the teen and an informant (usually a parent or guardian, if available), in order to gain a more comprehensive understanding of the teen's difficulties and to rule in or rule out a definitive diagnosis of depression.

Although not a screening tool, The Chehil and Kutcher Clinical Assessment of Adolescent Depression (CAAD, See Fig. 78.3) is designed to accompany the 11-item version of the KADS. Additional items found in the CAAD that are not present in the KADS-11 include assessment of current substance use and an overall rating of symptoms, function and safety.

Scores on the 11 items in the KADS are reviewed for both the following:

1. Frequency scale: Rated on a four-point frequency scale from “hardly ever” to “all of the time.”
2. Severity scale: Clinicians ask the teen and the informant to rate the severity of each symptom on a four-point scale (0–3) where

• “0” represents the absence of the symptom
• “1” is used to denote a symptom that is present but is experienced as mild and tolerable by the patient and is not associated with impairment
• “2” is used to denote a symptom that is present, is moderate in severity, is experienced as problematic by the patient but does not significantly impair the patient's functioning
• “3” is used to denote a symptom that is present and severe, difficult to tolerate, and associated with significant impairment.

On the basis of the information obtained from the teen and the informant, the clinician also provides a “composite” rating for each symptom using the same four-point scale. The CAAD can be used effectively by the clinician to conduct a detailed clinical interview needed to arrive at a diagnosis of MDD.

3. The RADSis an instrument used primarily on adolescents 13 to 18 years of age. It is a self-report, 30-item tool to screen for identification of depression and evaluation of treatment in adolescents. Internal consistency reliability has ranged from 0.92 to 0.96 and concurrent validity from 0.70 to 0.89 (Weber, 2000).
4. Children's Depression Inventory(CDI). The CDI, developed from the Beck Depression Inventory, is a self-rated instrument and represents five factors common to children and adolescents. It has been utilized in studies that have included various developmental ages and diverse ethnic populations. The construct validity of this test has been questioned in a study by Myers et al. (2002). They reported an internal consistency reliability of 0.59 to 0.88, a poor discriminate validity, and a high false-negative rate in adolescents.

Bipolar Disorder (Manic Depression)

If MDD occurs together with mania the diagnosis is bipolar disorder. This illness usually has its onset approximately 10 to 15 years postpuberty and is a chronic psychiatric disorder characterized by periods of depressed mood (which meet the criteria of MDD described earlier) and periods of significantly elevated mood (mania). Mania is characterized by intense energy, hyperactivity, elation, grandiosity, sleeplessness, racing thoughts, pressured speech, excessive risk-taking behaviors, excessive impulsive behaviors (such as spending sprees without the means to pay), and hypersexuality. In most teens with bipolar disorder, a “classic” MDE may be the first presentation of the illness; the initial diagnosis of MDD is revised after the first clear manic episode has been experienced. In some teenagers, an antidepressant medication can precipitate the development of a manic episode. While the following clinical points may be of help in identification of individuals at higher risk of bipolar disorder, at the present time we have no effective way of accurately predicting which teen presenting with MDD will go on to develop a bipolar disorder. The clinical points listed in the next section may be of help in identifying teens at higher risk of bipolar disorder.

Clinical Risk Factors for Bipolar Disorder in a Clinically Depressed Teenager

• Rapid onset of MDD
• Psychotic symptoms occurring together with MDD
• Family history of bipolar disorder

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FIGURE 78.1 Six-Item Kutcher Adolescent Depression Scale. (The Six-Item KADS is under copyright to Dr. Stan Kutcher. Use is with written permission only. Individuals wishing to use the six-item KADS can contact Dr. Kutcher at skutcher@dal.ca for permission.)

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FIGURE 78.1 (Continued)

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FIGURE 78.2 11-Item Kutcher Adolescent Depression Scale. (The 11-Item KADS is under copyright to Dr. Stan Kutcher. Use is with written permission only. Individuals wishing to use the 11-item KADS can contact Dr. Kutcher at skutcher@dal.ca for permission.)

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FIGURE 78.2 (Continued)

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FIGURE 78.2 (Continued)

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FIGURE 78.3 Chehil and Kutcher Clinical Assessment of Adolescent Depression. (The Clinical Assessment of Adolescent Depression is under copyright to Dr. Sonia Chehil and Dr. Stan Kutcher. Use is with written permission only. Individuals wishing to use the CAAD can contact Dr. Chehil at schehil@dal.ca or Dr. Kutcher at skutcher@dal.ca for permission.)

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FIGURE 78.3 (Continued)

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FIGURE 78.3 (Continued)

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FIGURE 78.3 (Continued)

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FIGURE 78.3 (Continued)

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A diagnosis of bipolar disorder is not to be made lightly. Concerns have been raised with recent increases in the use of a variety of thymoleptic medications (e.g., lithium, valproate) and antipsychotics (e.g., olanzapine, risperidone) to treat “bipolar spectrum” disorders in this age-group. Such interventions are not benign and carry risks of significant side effects. The use of these compounds by health care professionals in teens who demonstrate mood lability or persistent behavioral disturbances, but who do not meet rigorous DSM diagnostic criteria for bipolar disorder, is not encouraged. These interventions should be reserved for use in those disorders where these medications have been clearly demonstrated to be effective.

Anxiety Disorders

Anxiety symptoms which are mild, transient, and not associated with significant impairment are common in the adolescent population. However, many young people experience symptoms of anxiety that are severe and significantly affect their ability to function at school, in recreational activities, at home, in their relationships, or with their peers. As with clinical depression, teens who have anxiety disorders must experience certain clearly demarcated symptoms for a specified amount of time, which are associated with impaired function or significant distress. The diagnosis of an anxiety disorder is made using the DSM-IV-TR (American Psychiatric Association, 2000) or the ICD criteria (World Health Organization, 1992). There are a number of different yet related anxiety disorders which commonly occur during the adolescent years. These anxiety disorders include generalized anxiety disorder (GAD), social anxiety disorder (SAD) (also known as social phobia), panic disorder (PD), and obsessive compulsive disorder (OCD). Post-traumatic stress disorder (PTSD) may also occur in teenagers given the proper confluence of circumstance and constitution. Coexisting depressive symptoms are common and many teens may fulfill criteria for both depressive as well as anxiety disorders. In terms of the anxiety disorders themselves, these also often co-occur.

Generalized Anxiety Disorder

GAD is characterized by uncontrollable, excessive, and unrelenting worry that is inappropriate and not restricted to particular events or situations but rather involves many “usual” things such as safety of self and others, being on time, school work, performance, or illness. The worrying leads to significant emotional distress and functional impairment. Adolescents with GAD often also experience irritability, difficulty concentrating, and restlessness as well as many physical symptoms of anxiety such as recurrent headaches, stomach upset, muscle tension, fatigue, and sleep disturbance. Teens with GAD may experience social exclusion or bullying.

Panic Disorder

The onset of PD often occurs in mid to late adolescence and is characterized by recurrent, unexpected, rapid onset, time limited, intense episodes of severe anxiety (panic attacks) occurring in a crescendo–decrescendo pattern usually peaking within 10 minutes and lasting 30 to 45 minutes. Panic attacks are associated with autonomic hyperarousal, respiratory and cardiac distress, and cognitions of dread and fear. Adolescents with PD also experience anticipatory anxiety (the teen fears having an attack) between panic attacks as well as phobic avoidance (the teen avoids locations in which panic attacks occurred). Severe cases of PD can lead to agoraphobia.

Social Anxiety Disorder

SAD is characterized by excessive fears of social situations (e.g., public speaking, going to a party, standing up in class, changing in the locker room) in which the teen thinks that they are the subject of negative scrutiny by others. They feel embarrassed and anxious and may even experience panic attacks when faced with the dreaded social situation. They avoid or tolerate (with extreme difficulty) the feared situations and as a result experience social, interpersonal, and academic/vocational impairment. SAD in teens may be associated with school refusal or avoidance.

Obsessive Compulsive Disorder

OCD is characterized by the presence of recurrent, intrusive, unwanted thoughts or images that the teen knows are not true (e.g., “my hands are covered with deadly germs”) calledobsessions and/or repetitive physical or mental rituals (e.g., counting, ordering, washing) called compulsions. These symptoms create significant emotional distress and lead to functional impairment.

Post-Traumatic Stress Disorder

PTSD may occur in young people who are exposed to severe stressors that violate their personal safety (such as assault or rape) or in those who have witnessed or experienced a horrific event (traffic accident death, murder) or natural disaster (hurricane, earthquake). In addition to functional impairment, PTSD symptoms include reexperiencing the event (e.g., through dreams, flashbacks, vivid memories), persistent avoidance of situations or persons associated with the event, or increased hyperarousal. PTSD must be distinguished from the acute stress reaction which is a normal response to severe stressors and resolves over a period of a few months without clinical intervention.

Epidemiology of Anxiety Disorders

Anxiety disorders are very common in adolescents. At any one time up to one third of youth in the community may suffer from one of the anxiety disorders (Costello et al., 2005). Retrospective reports of adults with anxiety disorders suggest that the onset of anxiety disorders generally begin in childhood or adolescence. The incidence of anxiety disorders is greater in girls than boys, and girls tend to have an earlier age at onset than boys.

Risk Factors for Adolescent Anxiety Disorders

Like DD, anxiety disorders tend to run in families. A family history of parental anxiety or mood disorder has been

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shown to be a risk factor for an adolescent anxiety disorder. Other risk factors for the development of anxiety disorders include female gender, inhibited or anxious temperament, anxiety sensitivity, increased startle reflex, and increased autonomic reactivity (Merikangas, 2005; Costello et al., 2005).

Laboratory Evaluation for Depression and Anxiety

There are no diagnostic or laboratory tests that can be used to establish a diagnosis of depression or anxiety. Both depression and anxiety disorders are “clinical diagnosis” requiring the clinician to rely on current and longitudinal symptoms elucidated from the patient and informants where appropriate. All teens suspected of having one of these disorders should have a careful medical history and physical examination to rule out the presence of an underlying or contributing medical disorder. “Screening” tests for medical conditions which may present with depressive or anxiety symptoms such as thyroid stimulating hormone for hypothyroidism or thyroxine for hyperthyroidism are not cost-effective given their low positive predictive value in this population. If there is evidence from the history or physical examination to suggest the presence of a particular medical condition, the appropriate laboratory investigations should be carried out to confirm or reject the diagnostic possibility. Once a diagnosis of a DD or anxiety disorder is confirmed, a pregnancy test in adolescent females may be indicated if medication treatment is being considered.

Management

Baseline Evaluation

Once the diagnosis has been made, a proper baseline evaluation of the depressed or anxious adolescent must be conducted. This includes a measure of symptom severity and a measure of functional impairment. In addition, a baseline evaluation of somatic symptoms and psychoeducation should be conducted.

Symptom Severity

Symptom severity is best measured using an observer rated tool. For the depressed teen, the CAAD (Fig. 78.3) provides a useful clinical tool for measuring the severity of depressed symptoms in a teenager. It can also be repeatedly applied over the course of treatment to measure treatment response. Similar tools for anxiety disorders include the Screen for Child Anxiety Related Emotional Disorders (SCARED) or the Pediatric Anxiety Rating Scale (Birmaher et al., 1999; Research Units on Pediatric Psychopharmacology Study Group, 2002).

Functional Impairment

A simple, clinically meaningful, and easily applied measure of overall functional impairment is a four-point scale to ascertain the composite level of impairment as a summary of difficulties experienced in each of the following domains—family functioning, school functioning, work functioning, peer functioning, and recreational functioning. For each functional domain the following scoring system is suggested:

• 0: No problems in functioning in any domain.
• 1: Some problems in functioning in one or more domains (such as grades slipping at school, noticeable decrease in usual social activity; more family disagreements; more time spent watching television instead of outdoor activities).
• 2: Significant problems in functioning in one or more domains (such as clear evidence of decreased grades at school; avoidance of social interactions; increased family conflicts; lack of interest in usual recreational activities).
• 3: Significant problems in functioning in one or more domains and at least one domain with severe problems (such as not attending school; refusal to socialize with most friends; anger outbursts at family members; refusal to participate in usual recreational activities).

It is not unusual for adolescents with DDs or anxiety disorders to experience markedly poor functioning in one or two domains and moderately impaired functioning in others. In such situations, the domain(s) with the most impairment should be identified for particular attention.

A clinically useful tool that can be routinely used to measure a depressed or anxious teen's functioning at baseline and during treatment is the Clinical Measurement of Functioning in Adolescent Depression and Anxiety Disorders (Table 78.2).

Evaluation of Somatic Symptom Side Effects

Somatic symptoms should be systematically assessed at baseline and at appropriate intervals during treatment. Such an assessment will provide the clinician and the patient with useful information about which physical complaints are actually treatment emergent side effects and which are more likely to be somatic manifestations of the depressive syndrome or the anxiety disorder.

TABLE 78.2 Clinical Measurement of Functioning in Adolescent Depression and Anxiety Disorders

Domain of Functioning Score (0–3)a Comments aSee scoring scale in text. Family School Work Peer Recreation Overall

A simple but clinically useful side-effect tool such as the one found in Table 78.3 can be used at baseline and repeated at each clinic visit. A four-point scoring system as described in the subsequent text can be used to evaluate each somatic complaint:

• 0: Not present
• 1: Present but mild, tolerable, no impairment

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• 2: Present but moderate, some difficulty tolerating, some impairment may be evident
• 3: Present and severe, difficult to tolerate, impairment evident

Psychoeducation

Educating the teenager and the parents or guardians about the disorder and its treatment is a necessary part of the baseline evaluation. After an informed discussion, the treatment for the depression and the relevant anxiety disorder should be determined by consensus with all interested parties. Ongoing individual and family support will be needed. The adolescent and parents will benefit from practical advice on how to approach common problems. Clinician intervention with the school system is often indicated, especially if grades are a problem or behavioral difficulties have been identified by school officials.

TABLE 78.3 Somatic Side Effects Evaluation Scale

Item Score (0–3)a Item Score (0–3) Suicidal ideation _____ Suicidal intent _____ Suicide plans _____ aSee scoring scale in text. Dry mouth Headaches Drowsiness Insomnia Loss appetite Nausea Agitation Tremor Anxiety/nervousness Sweating Diarrhea Sexual problems

An appropriate period of psychoeducation before starting treatment is time well spent in the care of the depressed or anxious teenager. When properly conducted, it may serve to help establish a positive therapeutic relationship that will underlie whatever interventions are to follow. There is no rush to begin treatment (either medication or psychotherapy), as the only indication for emergency intervention is risk of self-harm or suicide (in which case hospitalization is required). A week to 10 days from time of diagnosis to the initiation of treatment will provide an opportunity for the teen and parents to read about the disorder and its treatments and to raise any issues that may come up. In addition to direct discussions, the clinician should have available scientifically valid literature on the topics and should direct the patient and family to appropriate Web sites for their own research.

Evidence-Based Treatments for Adolescent Depression and Anxiety Disorders

Current scientific evidence supports only a few interventions as having therapeutic efficacy for adolescent depression and anxiety disorders—SSRI medications (particularly fluoxetine and possibly sertraline or citalopram), psychological treatments (cognitive behavioral therapy [CBT], and interpersonal therapy [IPT]) (Harrington et al., 1998; Mufson et al., 2004;Ryan, 2005; AACAP, 2002; Waslick, 2005).

For adolescent depression, the best available scientific evidence favors fluoxetine (March et al., 2004) as the single best intervention and fluoxetine combined with CBT as the best intervention overall (March et al., 2004). Regardless of the intervention chosen, clinicians should be aware that the placebo response rates in the treatment of adolescent depression range from approximately 35% to 50%. The placebo response rate in the treatment of adolescent anxiety disorders appears to be lower than that seen in depression. Recent research suggests that the previous enthusiasm for the effectiveness of specific psychotherapies (CBT and IPT) in adolescent depression may have been overrated (National Institutes of Mental Health Meeting, 2006).

Both SSRIs and CBT have individually been found to be effective strategies in the treatment of a variety of anxiety disorders including GAD, SAD, and OCD. Unfortunately, there are no comparative studies addressing whether CBT or SSRI treatment alone is superior or whether combining the two treatment options has any added benefit for most of the anxiety disorders with the exception of OCD. The evidence for the treatment of OCD has shown that the combination of fluvoxamine with CBT or fluoxetine and CBT is superior to either alone. In general, the benefits of CBT for anxiety disorders are better than those found in the treatment of depression.

For adolescents with mild symptoms of depression and minimal functional impairment, a period of watchful monitoring following psychoeducation may be considered. A similar approach can be used with any of the anxiety disorders. This should include regular telephone contact, frequent face to face visits, and supportive problem-based counseling. Continuous evaluation of suicidality is required. If this does not lead to substantial symptom resolution over a period of 4 to 6 weeks, more intensive medical or psychological intervention is indicated.

For adolescents presenting with moderate to severe depressive symptoms accompanied by functional impairment, the initiation of medication or psychological treatments is indicated. This recommendation is similar for teenagers presenting with anxiety disorders. In some cases, the primary care clinician may not be trained to carry out CBT. If this is the case and referral for this intervention is not timely or possible, the use of cognitive therapy techniques (such as challenging dysfunctional thoughts and “all or none” reasoning) can be applied as part of ongoing support while medications are being prescribed. In all cases, ongoing monitoring of suicidality is required. Both at baseline and throughout treatment, the clinician should also address the issue of drug or alcohol use, abuse or dependence, as both depression and anxiety disorders increase the risk of substance abuse in young people.

If a depressed adolescent presents with psychotic symptoms or the clinician is concerned that there may be a psychotic disorder or bipolar illness underlying the depressive presentation, referral to an appropriate mental health professional for a thorough diagnostic assessment and perhaps hospitalization may be necessary. Suicidal intent or suicidal actions require a hospital admission to maintain safety and to provide immediate stabilization and proper evaluation.

Medication

While the recent controversies about SSRI medications causing suicide have been played out in the popular press, multiple independent investigations of the data by qualified

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groups and individuals have sufficiently addressed this issue and shown that SSRI use has not been associated with an increased risk of completed suicide. On the contrary, by playing a significant role in the treatment of teen depression, SSRI treatment may be protective and lead to a reduction in teen suicide. Recent prospective data (March et al., 2004) shows that the initiation of treatment with fluoxetine alone significantly decreases suicidality. Further, a health plan record analysis of SSRI use demonstrated a highly significant decrease in suicidality following the initiation of SSRI treatment in adolescents compared with the period before SSRI treatment (Simon et al., 2006). However, compared to placebo, SSRIs are associated with an increase in suicidal ideation and self-harm behaviors (but not completed suicide) (Cheung et al., 2005, 2006). As a result, the U.S. Food and Drug Administration (FDA) has issued a “black box” warning to advise consumers that these medications can cause these behaviors.

This data notwithstanding, prescribing clinicians require a good understanding of the pharmacokinetics and pharmacodynamics of these medications. This includes understanding the various physical and behavioral side effects that can be experienced as a result of the medication treatment. The most concerning of these behavioral side effects is enhanced suicidality (suicidal thinking) and possibly self-harm behaviors which can occur soon after the initiation of antidepressant treatment. Other behavioral adverse effects such as impulsivity, hostility, and restlessness can also be experienced by some patients. It is essential that the clinician inform the patient and family about the possibility of adverse effects, provide appropriate monitoring, and work out a contingency plan with the patient and family should the patient experience these adverse effects (Kutcher et al., 2004).

Individual Medication Categories

Selective Serotonin Reuptake Inhibitors

The SSRI medications, particularly fluoxetine, sertraline, and citalopram, have the best overall evidence supporting their use in the treatment of adolescent depression and anxiety disorders (Cheung et al., 2005; Wagner, 2005; Ryan, 2005). These medications work by blocking the reuptake of serotonin in presynaptic neurons. Doses for older adolescents parallel those of adults, whereas younger adolescents are generally started at lower doses and titrated upward more slowly. The advantages of the SSRIs are as follows:

• Minimal binding to histamine 1 (H₁), so less sedation and weight gain
• Minimal binding to α₁receptors, so less orthostatic hypotension
• Less binding to muscarinic cholinergic receptors, so less dry mouth, blurred vision, and constipation
• Do not potentiate effects of alcohol or sedative-hypnotic agents
• Once-daily dosing

Overall these medications are well tolerated and safe, with a much lower risk in overdose situations. However, there are also some disadvantages to consider:

• Inhibition of cytochrome P-450 enzyme system, which can lead to possible drug–drug interactions
• Sexual dysfunction including impotency and loss of libido can occur, which can reduce compliance
• Possible gastrointestinal side effects
• Disinhibition
• Induction or exacerbation of suicidality
• Precipitation of a hypomanic-manic episode

Given the available evidence, it is not possible to recommend the use of venlafaxine, nefazodone, monoamine oxidase inhibitors, or any tricyclic antidepressant (TCA) in adolescents. Randomized controlled trials (RCTs) of venlafaxine and TCAs have not shown these compounds to be significantly better than placebo in treating depressed adolescents younger than 18 or 19 years. While there is evidence for efficacy in adults, the number of individuals aged 18 to 25 in these studies is very small and therefore it is difficult to assess efficacy and safety in the young adult population. The FDA data base on child and adolescent pharmacotherapy identified that venlafaxine was the antidepressant most likely to be associated with suicidality in this age-group. The TCAs are known to have more cardiotoxic side effects than the SSRIs. Both these medications lack substantive evidence of efficacy, and the increased risk of use suggests that neither venlafaxine nor a TCA should be used in this population. Similarly, no RCT evidence for the efficacy, safety, and tolerability of Monoamine-oxidase inhibitor (MAOIs) exists in the teen population. The expected risk-benefit ratio of these compounds does not support their use in adolescent depression. Finally, nefazodone has not been demonstrated to be more effective than placebo treatment in this age-group. Bupropion may be considered as a second-line medication as there is theoretical rationale and some clinical evidence that this medication may be useful in teenagers with MDD who have comorbid attention-deficit hyperactivity disorder (ADHD).

Bupropion (Wellbutrin)

Mechanism of action: Bupropion is a dopamine reuptake inhibitor with some norepinephrine reuptake inhibition as well. It has stimulant–like properties, is well tolerated and may be particularly beneficial for patients with depression and significant psychomotor retardation. Bupropion is available in both regular-release as well as sustained release formulations. Only the sustained release formulation should be used for young people.

Advantages

• Minimal affinity for H₁, α₁, and muscarinic receptors
• Low risk in overdose situations
• Does not potentiate effects of alcohol or sedative-hypnotic agents
• No significant cytochrome P-450 drug–drug interactions
• Least likely to cause sexual dysfunction

Disadvantages of regular release bupropion

• Short half-life requires multiple dosing
• Higher risk of seizures with doses >450 mg
• Can have dose-dependent increase in blood pressure

Benzodiazepines

Although not well studied, clinical experience and some open label studies suggest that low doses of the benzodiazepine clonazepam (0.25–1 mg b.i.d.) may be of value in some of the anxiety disorders (such as PD). Some adolescents may experience a paradoxical response to a benzodiazepine characterized by agitation, insomnia, and disinhibition. If a benzodiazepine is to be used in teens, the clinician must look out for the occurrence of this paradoxical response and must inform the patient and caregivers that this might occur. Rapid onset, short-acting benzodiazepines should be avoided. Long-term use of benzodiazepines is

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generally not recommended and rapid discontinuation should be avoided whenever possible.

Antipsychotic Medications and Mood Stabilizers

Antipsychotic medications or mood stabilizers should not be used as first-line treatments for either depression or anxiety disorders. They may have some utility in highly specific and limited circumstances, for example, with psychotic depression or for treatment-resistant OCD where they can be used to augment antidepressants. Such augmentation strategies should be preceded by appropriate subspecialist consultation.

Prescribing Advice

Comfort with prescribing and monitoring antidepressant medications stem from knowledge and familiarity. An effective strategy to use in clinical practice is to choose a couple of antidepressant medications with demonstrated safety and efficacy in teens and use these compounds preferentially (Ambrosini et al., 1995). In this way, the clinician will become familiar with the range of effects that these compounds exhibit at different doses and in different individuals. Continued use of a small number of different medications will enable the clinician to build up an expertise with these medicines over time. Furthermore, given the available evidence pertaining to treatment effects of the SSRI compounds, the knowledge of two of these medications will be sufficient. On the basis of available literature, in order of preference, fluoxetine, citalopram, and sertraline would be reasonable SSRIs to choose. Table 78.4 provides a dosing guide using two of these SSRIs as an example for clinicians. Table 78.5 lists common SSRI medications and other antidepressant medications, including doses and side effects. Teens with anxiety disorders may be sensitive to the side effects of the SSRIs, particularly the activation side effects which generally occur early on in treatment.

TABLE 78.4 Examples of Selective Serotonin Reuptake Inhibitor Dosing in Adolescent Depression and Anxiety Disorders

Medication Generic Name Starting Dose Increments (mg) Effective Dose (mg) Maximum Dose (mg) Fluoxetine Prozac 5–10 mg q.d./o.d. 10–20 20 60 Citalopram Celexa 10 mg q.d./o.d. 10 20 60

Initiation

1. Lower initiation dose: Some clinicians choose to use lower initiation doses for teens with anxiety disorders. In addition, some clinicians may add a low dose of clonazepam (0.25 mg b.i.d.) for a week or two when beginning SSRI treatment to cover anxiety symptoms until the SSRIs are titrated to a therapeutic dose and their antianxiety properties begin to take effect. When initiating treatment with an SSRI in an adolescent, always start at a low dose (ideally at half the manufacturer's recommended initiation or lower) and increase gradually over a 1- to 2-week period to the initial target dose (see fluoxetine initiation and titration example in Table 78.6). It is a good idea to call the pharmacy used by the patient, to find out what the lowest available dose of the medication is. Sometimes starting with a liquid formulation may be reasonable if the dose available in tablets or capsules is higher than needed.
2. Expected time to improvement: In adolescent depression, significant symptom improvement may require 6 to 8 weeks following achievement of the initial target dose (e.g., 20 mg of fluoxetine daily) while remission may not be evidenced for 8 to 12 weeks. Similar time courses can be expected in the anxiety disorders apart from OCD in which significant symptom improvement may not become evident for 10 to 12 weeks (see Table 78.6 for fluoxetine initiation and dose titration). Care must be taken to ensure that the proper dose of medication is maintained for an appropriate length of time. Rapid dose increases are not likely to lead to faster or better improvement. This may in fact lead to more side effects. Ongoing psychoeducation, psychotherapy, or face to face counseling as described earlier is an important component of medication treatment.
3. Stopping treatment: With the exception of fluoxetine, which has a very long half-life, antidepressant medications should not be stopped abruptly. Sudden discontinuation may lead to a withdrawal syndrome. Symptoms of antidepressant withdrawal are outlined in Table 78.7. Given the demonstrated therapeutic benefits of these medications and the importance of monitoring for adverse effects the treatment and monitoring model discussed in the following text is suggested (Kutcher et al., 2004).

Patient Treatment and Monitoring Model

The model described in the subsequent text identifies the primary care practitioner as providing most of the care with ongoing consultation from the psychiatric specialist.

Patient Evaluation

1. Ensure that the adolescent has a DD or one of the anxiety disorders using DSM-IV criteria. Remember that DDs and anxiety disorders may be comorbid with each other. Clinicians should always assess substance (including alcohol) use, abuse, and dependence. The 11-item KADS in conjunction with the CAAD can provide a useful guide to the clinical assessment of adolescent depression.
2. Conduct a thorough psychiatric assessment addressing carefully other disorders which may present with depressive symptoms (such as a schizophrenia prodrome). Remember that the presence of depressive symptoms does not equal a clinical depression. Similarly, anxiety symptoms in the absence of an anxiety disorder should not lead to medical treatment.
3. Take a careful family history focusing on mood disorders and bipolar disorder. When obtaining the patient's present and past psychiatric history, complete a careful search for bipolar symptoms and substance abuse. Always inquire about a family history of anxiety disorders. Many of these anxiety disorders (in particular, PD) have strong genetic components.

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TABLE 78.5 Common Selective Serotonin Reuptake Inhibitor Medications and Other Antidepressants Medications Doses and Side Effectsa

Medication Dose Range Usual Dose Typical Dosing Half-life (hr) Anticholinergic (%) Sedation (%) Insomnia (%) Weight Gain Dizziness (%) Adverse Effects SSRIs, selective serotonin reuptake inhibitors. aIn the author's opinion, the risk : benefit ratio based on the currently available evidence does not support the use of tricyclics, MAOI's or venlafaxine in the treatment of adolescent depression. SSRIs Tier one: SSRIs with evidence-based use in adolescents Fluoxetine (Prozac) 20–80 mg/d 20 mg/d Once a day 48–216 10 12 17 ± 6 Nausea, anxiety, insomnia, diarrhea, anorexia, dry mouth Sertraline (Zoloft) 50–200 mg/d 50–100 mg/d Once a day 26–104 16 13 16 ± 12 Nausea, headache, diarrhea, sexual dysfunction (most common of all SSRIs), insomnia, dry mouth Citalopram (Celexa) 20–60 mg/d 20–40 mg/d Once a day 35 — — — — — Nausea, dry mouth, somnolence, insomnia, sweating, tremor, diarrhea, sexual dysfunction, dyspepsia, asthenia, anxiety, anorexia SSRIs not recommended for use in adolescents (without evidence-based use in adolescents) Paroxetine (Paxil) 10–50 mg/d 20 mg/d Once a day 10–24 18 23 13 ± 13 Nausea, sedation, headache, dry mouth, fatigue, insomnia Fluvoxamine (Luvox) 50–300 mg/d 100 mg/d 1–2 times/d 13.6–15.6 14 22 21 1% 11 Nausea, sedation, fatigue, headache, dry mouth, insomnia Other common antidepressant medications Tier two: Use in adolescents Bupropion (Wellbutrin) 200–450 mg/d 300 mg/d t.i.d. 8–24 27 20 19 ± 22 Agitation, dry mouth, constipation, headache, Nausea, insomnia, dizziness Bupropion sustained release 200–450 mg/d 300 mg/d b.i.d. — — — — — — Other common antidepressants not recommended for use in adolescents (without evidence-based use in adolescents) Nefazodone (Serzone) 200–600 mg/d 300–400 mg/d 1–2 times/d 2–4 25 25 11 ± 17 Nausea, somnolence, dry mouth, dizziness, constipation, asthenia, blurred vision Trazodone (Desyrel) 150–600 mg/d 100–300 mg/d b.i.d.–t.i.d. 4–9 18 29 5 ± 22 Drowsiness, dizziness, nervousness, dry mouth, Fatigue, nausea, headache, insomnia Venlafaxine (Effexor) 75–375 mg/d 75–150 mg/d b.i.d.–t.i.d. 5–11 22 23 18 ± 21 Nausea, headache, somnolence, insomnia, dizziness, dry mouth, Nervousness, constipation Venlafaxine extended release 75–225 mg/d 75–150 mg/d Once a day

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4. Determine the presence or absence of symptoms and the degree of functional impairment that the symptoms are causing. Measure the symptoms and the concurrent functional impairment appropriately. The CAAD can be used at baseline and for appropriate monitoring periods for depression. The SCARED (see preceding text) may be used for anxiety disorders.
5. Provide the patient and parent(s)/guardian(s) comprehensive information about the disorder and the various treatment options. Selected literature should be available in your office to share with the patient and parent(s)/guardian(s). Information sheets that provide appropriate Web sites can be given to the patient(s) for review. This type of information can be helpful to the patient and parents in their decision about medication. Refer patient and parent(s) to the Web sites identified at the end of the chapter.
6. Provide the patient and parent(s)/guardian(s) with all the information about somatic and behavioral side effects of the medication and the expected length of time to symptomatic improvement. Remember that in adolescent depression the time to improve might be longer than that of adults. Six to 8 weeks of medication treatment at an appropriate dose accompanied by supportive or cognitive based counseling is necessary for depression and most of the anxiety disorders. A longer period is needed for OCD. Providing this information in written form may be helpful.
7. Treat judiciously following a proper risk-benefit evaluation. A period of active monitoring in mild to moderately depressed or anxious adolescents is reasonable. This will allow the patient and parent(s)/guardian(s) time to digest the information provided and to weigh the pros and cons of different treatment options.
8. Provide opportunity for open dialogue and discussion regarding treatment options with the adolescent and family or other caregivers. Come to a joint decision about the most appropriate treatment.

TABLE 78.6 Fluoxetine (Prozac) Initiation and Dose Titration in Adolescent Depression and Anxiety Disorders

Day Dose (mg) Monitoring of Response a In adolescent obsessive compulsive disorder (OCD) this period should be lengthened for 14–21 more days because a longer period of time is needed to determine therapeutic response at a fixed dose in this disorder. 0 0 Patient assessment and baseline measurement of symptoms, function, and side effects 1 5 Check for side effects (by phone if not possible in person) 3 10 Check for side effects (by phone if not possible in person) 7 20 Check for side effects: If 10 mg is well tolerated increase dose to 20 mg 14–54 20 Check for side effects and monitor symptoms and function 54–75a 20 Check for side effects and monitor symptoms and function Decide on next steps regarding treatment depending on outcome

TABLE 78.7 Symptoms of Antidepressant Withdrawal Syndrome

Dizziness Headaches Weakness Anxiety/nervousness Nausea Difficulty sleeping Tremor “Electricity sensations”

If Medication Treatment is to be Initiated

1. Appropriately measure all somatic and behavioral “side effects” before initiating the intervention. Use a clinically useful scale (Table 78.3) at baseline. If the patient has a history of self-harm behaviors and exhibits significant restlessness and agitation, closer monitoring when starting an SSRI medication is indicated.
2. Check for symptoms of panic and impulsivity. The presence of these may suggest an enhanced sensitivity to the adverse behavioral effects of SSRIs. In cases of severe anxiety, short-term treatment with a benzodiazepine such as clonazepam may be indicated.
3. Begin treatment with a small test dose (ideally at half the dose recommended by the manufacturer for initiation) and increase gradually over a 1- to 2-week period to the initial target dose.
4. Carefully monitor for behavioral and somatic adverse affects during this initiation phase. Provide telephone contact opportunities. Address treatment emergent side effects as they arise. Use the telephone for patient contact between scheduled office visits.
5. Once initial therapeutic dose is reached, wait 6 to 8 weeks before increasing the dose further (10–12 weeks for OCD). During this time, provide appropriate psychotherapeutic interventions or ongoing counseling using face to face sessions weekly and establish telephone contact as necessary.
6. Conduct the appropriate laboratory investigations, not as a shotgun screening but when concerned about ongoing medical conditions. All female patients should have a pregnancy test.
7. If significant improvement is not obtained after 6 to 8 weeks of appropriate intervention (10–12 weeks for OCD) consultation with a psychiatric specialist is indicated.
8. If the intervention demonstrates only partial improvement, the treatment plan should be carefully reviewed, the diagnosis reconsidered, and treatment adherence addressed. If adverse effects are not significant, an increase in dose could be implemented at this time. If this strategy is not successful, switching to another antidepressant from the same class can be considered. In addition, a psychiatric consultation should be sought.

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9. The role of the primary care clinician, even if the patient has been referred to a specialist, should be continued throughout. Communication between clinicians is important and shared management of the depressed adolescent may be the most appropriate method of providing care.

Monitoring Throughout the Course of Treatment

1. Monitor for suicide risk.
2. Focus on enhancing the developments of a trusting and supportive relationship with the patient and family.
3. Measure objectively and subjectively the course of symptoms, side effects, and functioning.

Other Interventions

Anecdotal evidence and some limited research suggest that light therapy may be a potentially useful adjunct to other interventions for adolescent depression occurring in the winter months. Electroconvulsive therapy (ECT) may be indicated in very specific circumstances (psychotic depression) and should be provided by experts only under highly controlled conditions. There is no rationale for using ECT in the treatment of anxiety disorders. Transcranial magnetic stimulation and other biological treatments have not been well studied in this population.

Conclusions

Adolescent depression and anxiety disorders are significant public health problems. Adolescent depression can cause a high degree of morbidity and significant mortality usually due to suicide. Adolescent anxiety disorders can be significantly disabling and may be associated with substance abuse and other chronic life difficulties. Effective treatments are available and when properly administered can be helpful in the primary care setting. Evidence-based interventions should be used to guide treatment. Ongoing careful monitoring of therapeutic effectiveness and the presence of adverse events within the context of a supportive and trusting relationship is the cornerstone of effective treatment.

Primary care clinicians are in a unique position to develop and implement a treatment plan for the depressed teenager. Clinicians treating depressed adolescents will need to be well versed in the effective medication options available. To date, the SSRIs (specifically fluoxetine, citalopram, and sertraline) are the only class of antidepressant medications that have been shown to be safe and effective in treating depression in adolescents. In addition, fluvoxamine has proven effect in OCD. Careful monitoring of medication treatment and the judicious application of psychotherapeutic strategies is necessary.

Web Sites

For Teenagers and Parents

http://www.aacap.org/about/glossary/depress.htm. American Academy of Child and Adolescent Psychiatry.

http://www.nmha.org/infotr/factsheets/24.cfm. National Mental Health Association fact sheet and other information on adolescent depression.

http://www.nlm.nih.gov/medlineplus/depression.html. National Library of Medicine information regarding adolescent depression.

http://www.nimh.nih.gov/HealthInformation/anxietymenu. cfm. National Institutes of Mental Health information on anxiety disorders.

http://www.samhsa.gov/. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration information on adolescent anxiety disorders.

http://www.dbsalliance.org/. US Department of Veterans Affairs, National Center for PTSD information on PTSD in children and adolescents.

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