Depression and Suicide in Adolescents

00:01 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.

00:22 When we see a patient who we suspect of having depression, we need to ask about symptoms.

00:27 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.

00:43 These patients often complain of difficulty with sleeping or perhaps too much sleep. I is loss of interest.

00:50 We call this anhedonia. This is when they just don’t have anything that’s interesting to them.

00:56 G is guilt or negative feelings about themselves. E is a loss of energy which is very common.

01:03 C is a loss of concentration or cognition. These patients may be doing worse in school for example.

01:12 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.

01:30 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.

01:45 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.

02:21 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.

02:45 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.

03:42 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.

03:54 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.

04:13 When you examine a patient with depression, your exam may be completely unremarkable.

04:19 You may notice change in weight or you may notice signs of self-injurious behavior.

04:25 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.

04:44 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.

04:57 Additionally, it’s important to rule out substance abuse as a major cause of what’s going on.

05:03 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.

06:02 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.

06:16 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.

06:28 Other antidepressants may be used to for example increase availability of monoamines in the brain.

06:36 Some depressants such as tricyclic antidepressants have particularly toxic side effects.

06:43 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.

08:10 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.

08:30 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.

08:42 So, that’s my summary of depression and suicide in adolescents. Thanks for your time.