Adolescent depression. Part 2. Treatment.

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family history of depression, who is at high genetic risk and who has had previ- ous major depressive episodes, needs to be alerted to early symptoms of recur-.

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Adolescent depression Part 2. Treatment

F. JANE GARLAND, \ID, FRCPC

SUMMARY Treatment of adolescents with clinical depression is multimodal, involving pharmacologic, psychotherapeutic, educational, and family interventions. Medication has a limited role because of its lack of efficacy, its minimal effect on etiologic factors, and the frequent noncompliance of adolescents. Physicians should promote coping mechanisms and effective problem-solving styles to prevent recurrence of depression. I

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RESUME Le traitement de la depression chez les adolescents comporte de multiples modalites, incluant des interventions de nature pharmacologique, psychotherapeutique, educative et familiale. Les medicaments ont un r6le limite: leur efficacite est minimale, ils n'influencent pas les facteurs etiologiques et l'inobservance est un probleme frequent chez les adolescents. Les medecins devraient plut6t insister sur les mecanismes d'adaptation et les modalites efficaces de solution de probleme pour prevenir la recurrence de la depression. (an Fam Physician 1994;40:1591-1598.

repair the damaging effects of of depression in adults, the depression and to prevent its medication has a limited recurrence. role for treating adolescent depression. There are several reasons Comprehensive approach for this. First is the lack of efficacy (as The principles for treating adolescent described below) and second is the depression are: limited effect of medications on etio- * ensure confidentiality, logical factors. Because many risk * establish rapport, factors, such as anxiety, and develop- * assess suicide risk, mental and learning problems * involve the family, and persist, they must be addressed * maintain school supports. specifically because they perpetuate Adolescents can rarely be treated the depression. Third, adolescents are likely to be successfully without the active support nioncompliant with medication. They of the family and school. The teen's struggle with the idea of taking academic load might need to be adaptmood-altering substances recommend- ed, specific learning difficulties remedied by adults while they are developing ated, and school counseling provided anl independent identity anid are sub- to prevent development of school ject to peer pressure. Adolescents have avoidance behaviour. The family's commented that taking pills proves to inevitable frustration and criticism of them that they are "psycho." Finally, the depressed teen's "laziness" needs to those adolescents who have developed be changed, and other contributing clinical depression really need environmental factors addressed. The comprehensive approach to coping mechanisms and effective problem-solving styles in order to help adolescent depression includes some common sense measures, such as sleep Dr Garland is a ClinicalAssiStant Professor hygiene, regular meals, exercise, time at the Universipy of British Columbia and is management, and combating social withdrawal. The immobilized, Director of the Child and Adolescent Mood overwhelmed teen needs help with Disorders Clinlic in the Department of P4ychiat.r at the University Hospital-UBC Site in setting priorities to combat helplessness Vancouver. and hopelessness. A support system of AN CONIRAST T1 HI 'ITRIAl'MENTI

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Adolescent depression Part 2. Treatment

adults and peers who will not simply give advice but will promote strengths and problem-solving is crucial. Depressed individuals need to take control of their lives because this is the antidote to hopelessness. Social skills and assertiveness training, stress management, and cognitive-behavioural strategies are among the more specialized tools that will benefit depressed adolescents. Secondary prevention is an important aspect of the comprehensive approach. Risk reduction and improved coping strategies help to deal with factors that are often persistent. Understanding the role of these etiologic factors is critical for treating each individual case. For example, a young person with a strong family history of depression, who is at high genetic risk and who has had previous major depressive episodes, needs to be alerted to early symptoms of recurrence and taught preventive strategies and coping mechanisms to use while an active biological approach to treatment and maintenance therapy is instituted. On the other hand, an adolescent with a weak family history of depression and a strong history of developmental problems or psychosocial stressors will require a primarily psychotherapeutic and behavioural approach to prevent caring

recurrence.

Managing suicidal thoughts. Adolescents are at special risk for suicidal behaviour. Follow-up studies have shown that depressed adolescents are at very high risk.' One study showed that the most common method of completing suicide was tricyclic antidepressant overdose.2 While younger children have suicidal thoughts in the context of depression, they more rarely act upon them, perhaps because they lack the ability to formulate and carry out a plan. However, age of first suicidal behaviour might be declining, likely due to children's greater awareness of potential methods, especially overdosing on nonprescription medications. Suicidal thoughts arise from a sense of hopelessness and isolation. The first 1592 Canadian Family Physician VOL 40: September 1994

in preventing suicidal behaviour in depressed adolescent is to develop rapport and a therapeutic relationship in which isolation is reduced and hopelessness combated by the more optimistic view of a physician or other professional. Emergency telephone numbers, crisis lines, or the ready response of a family physician or counselor are especially important for this age group. Adolescents will rarely abuse a 24-hour phone line to a physician, and this could be lifesaving. step

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Role offamily therapy. In some cases, a depressed adolescent is the symptom of a family problem, and treatment could be ineffective if the problem is not identified at its source. An example is a severely depressed 15-year-old who was resistant to psychotherapy and pharmacotherapy with full trials of two serotonergic reuptake inhibitors and a tricyclic antidepressant, failed to improve with psychiatric hospitalization, and remained functionally impaired and suicidal. During a second hospitalization, the family secret came to light. Mother had a long-standing affair with another man who was in the role of substitute father for the children but needed to be concealed from their biological father. Chronic but unacknowledged marital conflict was fueling the hopelessness and helplessness of this bright teen. She felt responsible but paralyzed and was very much caught between the parents. Her depression finally began to resolve, without any medication, as the family faced the situation directly. Adolescents most vulnerable to developing "symptomatic" depression are those who are introverted, anxious, and conscientious, often excessively enmeshed in their parents' problems and taking precocious responsibility for the well-being of the adults in the family. Parental depression or other serious psychiatric disorders, substance abuse, and covert marital problems are examples of the kinds of family problems an adolescent might be masking. Indeed, the adolescent's symptoms could be the

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Resources for nonpharmacologic interventions. The time-consuming work of nonpharmacologic intervention can be shared. Family physicians can draw upon many skilled community resources, such as school counselors, mental health centres, family services and social agencies, alcohol and drug programs, psychiatrists, psychologists, social workers, and other trained family therapists. It is crucial, however, that these agencies communicate with primary physicians and that all of the therapeutic interventions are integrated rather than contradictory. A safety net is created by parents, schools, physicians, and other agencies operating together on behalf of a depressed adolescent. Conflicting approaches and disagreement among the family, school, and various other professionals will only increase an adolescent's sense of isolation and discouragement.

Psychotherapy Table 1 outlines psychotherapeutic approaches to adolescent depression. The emphasis is on cognitive therapy and behavioural strategies that not only help to resolve the current episode but will also make enduring changes in social and cognitive behaviours in order to prevent recurrent depression in high-risk individuals.

Principles of cognitive therapy. Cognitive therapy has been proven as efficacious as, or better than, medication for mild and moderate depression among adults. While research on the efficacy of group cognitive therapy for adolescents and cognitive-behavioural therapy for anxiety and impulse control disorders exists, research protocols

for individual cognitive therapy for depressed adolescents have not been developed.3 However, cognitive distortions are well demonstrated in depressed adolescents.4'5 The appeal of cognitive therapy for adolescents is that they are still learning and their cognitive style is more flexible than adults. In my experience, teens acquire cognitive-behavioural skills more rapidly than adult patients with mood disorders. Furthermore, the skills help teens gain some control over their lives and counteract learned helplessness. Family physicians can readily undertake cognitive therapy; they have the advantage of an already established therapeutic alliance. The principle behind cognitivebehavioural therapy techniques is that depression is exacerbated, and might even be caused, by "depressogenic" cognitions, ways of thinking that are self-defeating and promote depression. The learned helplessness model has demonstrated the behavioural consequences of this kind of conditioned attitude in animals. Animal models also demonstrate the associated biochemical changes in the brain that accompany this behaviour. Describing to adolescents the model of helpless rats is often a helpful starting point for them to see their behaviour as "logical" given their experience. The individual who has succumbed to learned helplessness typically believes that "It's no use trying; it never works out for me anyway; I never do anything right; everything always goes wrong" and so on. A negative interpretation of events reinforces these beliefs. For example, when classmates walk past in the school hallway without acknowledging the depressed adolescent, the adolescent assumes: "They don't like me; no one likes me; I'll never have any friends." Depressive behaviour reinforces this belief. Depressed adolescents do not smile, do not make eye contact, and look at the floor; inevitably others will be less likely to greet them in the hall. This then "proves" the belief that they will never

Adolescent depression Port 2. Treatment

Table 1. Psychotherapy

COGNITIVE THERAPY * Remediate depressogenic cognitions *

Encourage problem solving

BEHAVIOURAL CHANGES * Improve social skills * Practise coping strategies * Introduce exercise * Encourage sleep hygiene * Foster time management

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Table 2. Steps in cognitive therapy COGNITIVE THERAPY IN THE OFFICE Introduce the concept * Thought patterns promote depression * Errors and assumptions are made * Catastrophic outcomes are presumed * The body reacts as if it has already happened * You then behave according to beliefs Use an example from the patient's situation Link the concept to life experiences that might have "taught" the patient this way of thinking

Point out that new habits will have to be practised

Begin the strategies

COGNITIVE THERAPY STRATEGIES Identify a situation in which the patient felt depressed Review thoughts associated with these feelings * Automatic * Negative * Self-focused

Identify triggering situations and events

Identify cognitive errors that occurred

Develop alternative interpretations and conclusions

have any friends or that it is no use trying. Cognitive therapy challenges this belief, reexamining the evidence and seeking alternative explanations for the classmates' unfriendly actions. "Perhaps they had other things on their minds, were worried about a test, were shy, thought I didn't want to talk because I was avoiding eye contact," and so on. This is followed by behavioural "experiments" to test out these other hypotheses. The cognitive-behavioural approach for young people is reviewed in detail elsewhere,3 but the general approach can rapidly be mastered by family physicians and applied in a brief counseling approach outlined below.

Cognitive therapy strategies. During several 20-minute sessions scheduled about every 2 weeks, cognitive behavioural therapy can be introduced to teens in a psychoeducational style (Table 2). First, introduce the concept, using a simple example of how negative beliefs are self-reinforcing. The assumption of "catastrophic" outcomes occurs in daily life on flimsy evidence. Teens can usually think of an example that has happened in the previous few days. Physicians should then explain that "your mind dwells on that worst case scenario, and your body reacts as if that awful thing has already happened, so you feel terrible, and chemical changes of depression start to happen." When you describe how this idea is well supported by animal and human models, most adolescents will find the concept quite interesting. The implication is that they have control over some aspect of their lives, which often feel out of control. Review a typical recent example from a patient's own experience, looking at the assumptions and errors of thinking that occurred. After this first discussion, ask teens to look for more examples before the next meeting. This "homework" extends the effect of physician contact outside office time.

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Cognitive therapy does not preclude understanding of the origins of psychological problems. One additional idea that can be readily introduced is to touch on the life experiences that "taught" the adolescent this way of thinking. Risk factors, such as abandonment, abuse, learning disabilities, medical illness, parental separation, and so on, can be integrated and linked to the current depressive way of thinking. In this sense, what appears to be a purely cognitive type of therapy in fact has an insight-oriented component. Presented in a psychoeducational an

way, it helps adolescents make sense out of what have been overwhelming emotional responses to overwhelming life experiences. At the next meeting, one or two of the previous week's examples should be examined in detail, looking at the event, the assumptions, the emotional response, and alternative explanations for the events. Adolescents are then given more "homework" of trying out a behavioural change, such as deliberately making eye contact and smiling, to see if this changes experience. Other activating behavioural steps, such as exercise or the use of structure, can also be added in as "experiments" to see if they do make a difference in the depressed mood. It is important to point out that just as negative ways of thinking and behaving have been "practised" for a long time, the new ways of thinking and behaving will need practice too. Among the tools for cognitive therapy are logic, humour, and creativity. The result of this approach is a more assertive and less dependent adolescent. The general behavioural approach that accompanies cognitive therapy leads to more effective problem solving and taking control wherever possible. The only "side effect" of this is that others in the family or social network might resist this new assertiveness and confidence. This needs to be anticipated with a systems approach. Cognitive-behavioural changes need to be practised, but they rapidly prove

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themselves effective to adolescents, who then become their own therapists. Various books written for adult patients can also help adolescents develop greater understanding and more strategies for changing depressogenic cognitive distortions.6 Physiciancoaches can then positively reinforce these steps through infrequent booster sessions.

Pharmacotherapy Antidepressant medication has been surprisingly inefficacious for adolescents. In contrast to open studies, placebo-controlled, double-blinded research protocols have failed to demonstrate any benefit of medication over placebo for adolescent depression.7'8 Up to 60% of adolescents recover while receiving placebo; up to 70% recover using medication.8 This finding applies to traditional tricyclic antidepressants, such as imipramine, desipramine, and nortriptyline, and also to serotonin reuptake inhibitors, such as fluoxetine. However, numbers in studies of the more recent medications have been limited.

compulsive disorder, panic disorder, bulimia, and attention deficit disorder. Despite the lack of demonstrated efficacy of antidepressant therapy for adolescents, some leading researchers point out that, once placebo responders have been eliminated, a group of patients who appear to respond well to

Adolescent depression Part 2. Treatment

medication remains.8 Therefore, a trial of medication is justified when a serious major depressive episode fails to

respond to nonpharmacologic interventions. Many of these patients have prominent neurovegetative symptoms

including severe sleep disturbance, weight change, and marked functional impairment. This approach has produced excellent results in specialty mood disorder clinics, which tend to see more severe cases that have not responded to other treatments. If the clinical situation indicates medication, which medication is appropriate? Table 3 ouflines suggested medications. Factors to consider are the safety profile, side effects, effectiveness of the medication for depression and comorbid conditions, cost, and likelihood of compliance with treatment.

When is medication indicated? Tricyclic antidepressants. Most of Medication should be considered early the earlier controlled studies found limin treatment for certain situations: ited evidence of efficacy for this class of antidepressant, especially imipramine, psychotic episodes, vegetative symptoms, desipramine, and recently nortripsevere functional impairment, tyline. Because tricyclics are lethal in overdose, they cannot be used if there bipolar disorder, panic disorder, is a risk of suicidal behaviour, despite obsessive compulsive disorder, and their low cost and long history of use. strong family history of depression. Limiting the amount of medication or placing it in the care of a family memPsychosis and bipolar disorder usu- ber are possible solutions if tricyclics ally require psychopharmacologic are otherwise strongly indicated. Side intervention in the form of antipsy- effects, such as anticholinergic effects, chotics, benzodiazepines, and mood- sedation, and postural hypotension, are stabilizing agents, such as lithium and common and limit compliance. carbamazepine. The approach is simi- However, for certain young people, lar to that for adults and is reviewed especially those with comorbid obseselsewhere.9 Medication should be con- sive compulsive disorder, attention sidered seriously when there are deficit disorder, or panic disorder, tricomorbid conditions for which antide- cyclics are the drugs of choice. Also, pressant medications have clearly been controlled studies have shown demonstrated effective, even for ado- desipramine helpful for attention lescents.'0 These include obsessive deficit disorder and bulimia, and 0

Table 3. Antidepressants of choice for teens

TRICYCLIC ANTIDEPRESSANTS * Desipramine * Nortriptyline

SEROTONIN REUPTAKE INHIBITORS * Fluoxetine * Fluvoxamine * Sertraline

REVERSIBLE MONOAMINE OXIDASE INHIBITORS * Moclobemide

OTHERS (SPECIFIC INDICATIONS) * Phenelzine * Lithium * Clomipramine

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clomipramine is clearly effective for and treatment must be on assisting the young person to develop more effecobsessive compulsive disorder."1 Serotonin reuptake inhibitors. Because overdoses are not lethal, side effects are minimal, and they have an activating effect on anergic adolescent depression, serotonin reuptake inhibitors are the practical drugs of choice. Comorbid obsessive compulsive disorder, bulimia, and some panic disorder cases will also respond.1° Preliminary observations on the efficacy of fluoxetine for attention deficit disorder and impulse control disorders suggest that it might be more widely used if supported by future research. Anorgasmia is one upsetting side effect for some patients.

tive coping skills and a more positive cognitive and behavioural style. Current studies are examining the effect of psychological and pharmacoU logic treatments on outcome.

Requestsfor reprints to: Dr E.1]. Garland, Child and Adolescent Mood Disorders Clinic, Department of Psychiatry, Universily Hospital, 2211 Westbrook Mall, Vancouver, BC V6T2B5

References 1. Rao U, Weissman M, MartinJ, Hammond R. Childhood depression and risk of suicide: a preliminary report of a longitudinal study. J Am Acad Child Adolesc Psychiatry 1993;32:2 1-7. 2. Kovacs M, Goldston D, Gatsonis C. Suicidal behaviors and childhood-onset depressive disorders: a longitudinal investigation. 7 Am Acad ChildAdolesc Psychiatrv 1993;32:8-20. 3. Kendall P, editor. Child and adolescent therapy: cognitive-behavioral procedures. New York: Guildford Press, 1991. 4. Marton P, Coniollyj, Kutcher S, Korenblum M. Cognitive social skills and social self-appraisal in depressed adolescents. J Am Acad Child Adolesc Psvchiatry 1993;32:739-44. 5. WVeiszJ, StevensJ, CurryJ, Cohen R, Craighead W, Burlingame M; et al. Controlrclated cognitions and depression among inpatient children and adolescents. JAm Acad

Other pharmacologic agents. Special situations call for other drug classes. Monoamine oxidase inhibitors are effective for the atypical depression panic disorder, and social phobia often present in adolescent depression. Dietary restrictions, postural hypotension, and sexual dysfunction might limit compliance, and the risk of serious hypertensive crisis is worrying. The introduction of moclobemide, a reversible monoamine oxidase inhibitor that has no dietary restrictions that is helpful for anxious depresChildAdolesc Psvchiatry 1989;28:358-63. sion and that might also be useful for 6. Burns D. Thefeeling good handbook. New York: atypical depression, could solve these Plume Books, 1991. problems. Overdoses of moclobemide 7. Weller E, XVleller R. Depressive disorders in have not proved fatal to date. children and adolescents. In: Garfinkel B, Finally, using lithium as augmenta- Carlson G, WVeller E, editors. Psychiatric tion or for recurrent depression, can be disorders in children and adolescents. Philadelphia: considered for adolescents as for adults, WVB Saunders Co, 1990:3-20. although specific effectiveness for ado- 8. Ambrosini P, Bianchi M, Rabinovich H, lescents has not been demonstrated. EliaJ. Antidepressant treatments in children Conclusion The social, psychological, and developmental costs of adolescent depression are well documented. In most cases comprehensive psychosocial intervention is more effective treatment than pharmacotherapy. Because of the risk of recurrence and the presence of identifiable, persistent risk factors, emphasis during both evaluation 1598 Canadian Family Physician VoL 40:

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and adolescents: I. Affective disorders. JAAm Acad Child Adolesc Psychiatry 1993;32: 1-6. 9. WVeller E, Wecller R. Mood disorders. In: Lewis M, editor. Child and adolescent p.sychiatry: a comprehensive textbook. Baltimore: Williams and WVilkins, 1991:646-63. 10. Ambrosini P, Bianchi XI, Rabinovich H, EliaJ. Antidepressant treatments in children and adolescents: II. Anxiety, physical and behavioral disorders. J Am Acad Child Adolesc Psyc.hiatry 1 993;32:483-93.