In this lecture, we’re going to review depression and suicide in adolescents. This is a huge problem
in the United States. It is both common, we see it all the time, and severe. It’s a major cause of death
in the US. So, let’s go through it together. It’s important that we review this topic.
When we see a patient who we suspect of having depression, we need to ask about symptoms.
We can’t just simply say, “Are you depressed?” There are several symptoms. They can be remembered
in the mnemonic, SIGECAPS. I’d like to go through that mnemonic with you. S stands for sleep disturbances.
These patients often complain of difficulty with sleeping or perhaps too much sleep. I is loss of interest.
We call this anhedonia. This is when they just don’t have anything that’s interesting to them.
G is guilt or negative feelings about themselves. E is a loss of energy which is very common.
C is a loss of concentration or cognition. These patients may be doing worse in school for example.
A is appetite changes. Have they either gained or lost weight recently. P is psychomotor agitation
or retardation. Patients might be moving too much while you’re talking to them or they may be very, very still.
S is suicidality. We need to screen all of our adolescents for the potential for suicidality
during their regular visits. So, the DSM has a definition of depression which I think we should review.
Depression, they say, is a chronic or recurrent mood disorder characterized by reduced functioning
in more than one major area of life. Those areas of life for example are academics, familial interactions,
or peer relationships. So when we have a patient with depression, we generally can break that down
into a major depressive episode or a major depressive disorder. A major depressive episode
is persistence of five or more of those SIGECAPS symptoms in the same two-week period.
A major depressive disorder is two or more major depressive episodes. So, if a patient has had many
episodes of depression, they are now categorized as having depression. The prevalence of depression
in the US is common. It’s present in about 1% of children and 8% to 10% of adolescents.
One in ten adolescents has depression. While before puberty, the gender ratio is even, after puberty,
females are twice as likely to be depressed as males are. There are proposed mechanisms
that this happens such as a low brain level of serotonin. But this is probably a gross simplification
of what is actually going on inside the human brain. There are certainly genetic and environmental
predictors of depression. So, what are some risk factors that we worry about in the environment
that might put someone at increased risk? Certainly, increased family history, presence of substance abuse,
or suicidality in the family may be both genetic and environmental. Chronic illness puts children
at increased risk for depression. Poor relationships with their parents put children at increased risk.
Also, obviously child abuse and neglect can leave a child more likely to develop depression
when they are then an adolescent or it can be an active abuse situation as an adolescent.
Rejection or victimization by peers is a common cause of depression. Bullying in the United States
is a national problem. Likewise, negative life events can cause depression. But there are some
individuals who have negative life events who don’t get depressed. So, it’s a complex issue.
When you examine a patient with depression, your exam may be completely unremarkable.
You may notice change in weight or you may notice signs of self-injurious behavior.
In adolescent girls, cutting is very common. It’s a way they can try to get control over their life
but it’s a way that doesn’t really help in the long term. It’s important when seeing a patient
with depressive symptoms to ask yourself if there is another possible psychiatric diagnosis.
One example for example is bipolar disease where patients have periods of depression offset by patients
by periods of mania. So, ask about that. Ask if there are times when they are perhaps hyperproductive.
Additionally, it’s important to rule out substance abuse as a major cause of what’s going on.
When we see patients with psychiatric depression, it is possible although rare that it’s not actually
a psychiatric condition but rather is organic in nature. Examples might be hypothyroidism, anemia,
or nutritional deficiencies, obstructive sleep apnea, or CNS lesions. So, how do we treat depression
in adolescents? First and one of the mainstays is psychotherapy. Cognitive behavioral therapy
is important in treating adolescents with psychiatric conditions. They need to find a practitioner
they can trust. The challenge is that not every psychotherapist necessarily is a perfect match
for that adolescent. One thing I often tell parents is if they don’t like a particular psychotherapist,
they should continue to look for another one that’s working for them rather than just give up.
Interpersonal therapy is important. Medications are also important in the management of depression
in adolescents. Usually, our first line agent is an SSRI or a serotonin specific reuptake inhibitor.
This is usually where we start. Because pediatric psychiatrists are sometimes hard to find
in some communities, many primary care pediatricians feel comfortable prescribing SSRIs.
Other antidepressants may be used to for example increase availability of monoamines in the brain.
Some depressants such as tricyclic antidepressants have particularly toxic side effects.
So, it’s important to understand the side effects of psychiatric medications. We also need to manage
comorbidities in these patients. So, if they have substance abuse, we have to address that
and get them into our program. Patients with eating disorders sometimes need special programs
that address specifically eating disorders to help them get past that difficulty. Also, if anxiety
is a major component, we may need to manage anxiety with different medications then we’re managing
their depression. So, let’s focus a little bit on suicide. Suicide is the third leading cause of death
in adolescents in the United States. What’s interesting is there’s a difference between genders
regarding suicide. Females attempt suicide 2-4 times more often than males do, often for example
by taking pills. But males complete suicide 3-4 times more than females. So, a male is less likely
to try to commit suicide but his modality of attempt is going to be much more significantly successful,
for example jumping in front of a bus. So, when we see patients who have attempted suicide,
there are a few things we need to drill down on. We need to find out if there have been previous attempts.
So, we can understand how longstanding this severe depression has been going. We need to evaluate
for mood disorders. We need to check for substance abuse. We have to ask about family history
especially family history of mental illness and suicide. It’s important to ask about a sexual history.
The reason is because sexual history, sexual abuse, and physical abuse is much higher
likely to have occurred in patients who have committed suicide or attempted suicide.
So, that’s my summary of depression and suicide in adolescents. Thanks for your time.