Depression and Suicide Prevention in Adolescents and Children

Childhood and adolescent depression is a significant but often under-recognized threat to the well-being of youth. It is easy to miss because young people tend to have a wider range of moods than their adult counterparts, especially exhibiting irritability or feeling Òbummed outÓ on occasion. However depressive disorders are present in pediatric populations. Understanding them, recognizing them, and taking measures to help prevent the drastic consequences of major depression is the responsibility of the health care team, parents, teachers, and community leaders that interact with at-risk children.

Depression has been recognized by the World Health Organization as one of the Òmost disabling of all diseases in the world.Ó Major Depressive Disorder (MDD) is defined in the DSM-IV (Diagnostic and Statistical Manual for Mental Disorders) for both children and adults as follows:

At least one of the following 2 symptoms must be present to make the diagnosis:

• depressed or irritable mood most of the day nearly every day
• diminished interest or pleasure in activities relationships

And either 3 or 4 of the following:

• Decreased/increased appetite, weight loss/gain, failure to achieve expected weight gain (especially important in kids)
• Insomnia/hypersomnia
• Psychomotor agitation/restlessness or motor retardation
• Low energy or fatigue
• Feelings of worthlessness or excessive guilt
• Indecision, poor concentration and memory
• Recurrent thoughts of death or suicide

At least 5 symptoms are present during the same 2 week period and represent a change in functioning. These symptoms are not better explained by any other diagnosis or a general medical condition.

Epidemiology

    1.Children can be depressed at any age, with increasing prevalence in adolescence.

    2.Peak ages of onset of depression are 15-19 years and 25-29 years old.

    3.2% of school-age children and 4-6% of adolescents have MDD at any one time.

    4.Before puberty the gender ratio for depressive disorders is 1:1.

    5.After puberty it is a 2:1 ration of females:males. This continues into adulthood.

    6.50% of children and adolescents who have MDD will have recurrences as adults.

Suicide is the 3^rd leading cause of death in children and adolescents.

• 80% of youth who attempt suicide and 90% of youth who complete suicide have a history of a psychiatric or mental disorder: this includes depression, substance abuse, conduct disorder, aggressive behavior patterns, and anxiety disorders.
• Note: 50% of adolescent males and 66% of adolescent females who successfully commit suicide suffered from depression.
• 32% of depressed youth will have at least one suicide attempt before adulthood
• 85% of depressed youth have significant suicidal ideation
• Firearms are the leading cause of death by suicide for both males and females
• Suicide rate for ages 5-14 years: 0.8 per 100,000
• Suicide rate for ages 15-24 years: 11.1 per 100,000
• Prevalence of Suicidal Ideation in adolescents (15-19 yrs): M 11-14%, F 18-25%
• Prevalence of Suicidal Attempts in adolescents: M 4-6%, F 11%
• Prevalence of Completed Suicide in adolescents: M 13.3/100,000, F 2.8/100,000

Risk Factors for Depression

- Can be genetic

- Often precipitated by a major stressor (changing schools, parents get divorced, breakup with boyfriend/girlfriend, etc.)

- Maltreatment (sexual, emotional or physical abuse and neglect)

Differential Diagnosis for Major Depressive Disorder

1 Bipolar disorder

      2 Dysthymic disorder (often overlooked, but can casue as much, or more impairment in function thanMDD due to extended course)

      3 Substance abuse (often comorbid)

      4 Anxiety disorder (often comorbid, especially in girls)

5 Conduct disorder (often comorbid, especially in boys\
6 Mood disorder related to a medical conditio (hypothyroidism, Addison's disease, postconcussive syndrome, Vit B12 deficieincy,  SLE, Mononucleosis, HIV)
7 Bereavement
8 Adjustment disorder with depressed mood
9 Post-traumatic stress disorder (often comorbid, especially in boys)
10 Attention-deficit hyperactivity disorder (often comorbid)

Between 40-70% of depressed children and adolescents have comorbid psychiatric disordrers

Risk Factors for Suicide

- Strongest predictor of future suicidal behavior = history of previous attempt

- Suicidal ideation

- Exposure to someone who also attempted or completed suicide (friend/family)

- Current Depressive Disorder, Bipolar disorder, Substance Abuse, Conduct Disorder or other psychopathology

- Aggressiveness, impulsivity, hopelessness (sign of depression)

- Lack of connectedness with parents

- Parent with substance abuse problem or psychopathology

- History of physical/sexual abuse, violence, or conflict

- Homosexual orientation

42% of gay, lesbian, bisexual adolescents experience suicidal ideation

28% have attempted suicide at least once in the past year

- Access to firearms, toxic chemicals or medications, or other means

- History of adoption

Protective Factors Against Suicide

- Parenting skills that emphasize praise for positive behavior

- Increase in amount of time that parents spend with children

- Strong parent-family connectedness

- Restricted access to guns or other weapons

- Restricted access to alcohol, marijuana, or other drugs

How to Approach an Adolescent who may be at risk for Suicide

1. Know the risk factors.
2. Ask about suicidal ideation. Is there a plan? Intent? Access to a weapon? Has it happened before? What happened?
3. Ask about firearms in the home. Recommend that they be removed.
4. Recognize signs of depression. This may present in typical form: insomnia or hypersomnia, change in weight, depressed mood, feelings of helplessness. However, in adolescents, it often presents in other ways such as behavioral problems (truancy, violence, self-destruction, running away from home, sexual acting out, etc.), difficulty with academic performance, or psychosomatic complaints (abdominal pain, headache, dizziness, chest pain, etc).
5. Recognize the psychiatric needs of an adolescent with signs of risk for suicide. If the patient admits to a having a plan or has a history of a previous attempt and is now exhibiting warning signs of a repeat attempt, this patient should get an immediate psychiatric evaluation and probably be admitted to an inpatient unit until his/her safety is no longer at risk. Hospital stays are usually brief and are meant to stabilize and evaluate the patient and arrange for close follow-up.
6. Although not all adolescents with depression will require pharmacotherapy, it is important to know that SSRIs (Selective Serotonin Reuptake Inhibitors) are the antidepressants of choice for young people with depression. These drugs may take 4-6 weeks to take effect. Unless there are significant adverse effects from the drugs, SSRIs should be continued for 6-12 months to help achieve remission from the depression. CAUTION: There is a small but real increased risk of suicidal thoughts or behavior (ut not complete suicides) in children taking antidepressants compared with placebo. This effect is hypothesized to be due to an increase in energy which is not yet balanced by improved feelings of emotional well-being.  Most mental health specialists agree that, if indicated, the benefits of antidepressants therapy outweigh the risks.
   
7. Psychotherapy such as Cognitive-Behavioral Therapy and Interpersonal Therapy may be useful in helping youth learn to cope with and overcome depression. Family therapy may also be useful.
8. Even after treatment has been established, continue to monitor for risks of suicide by asking about suicidal thoughts and behaviors. Schedule frequent visits and follow-up when the patient does not show. Make sure the patient and his/her guardians are aware of accessible 24-hour emergency services.

1. Hatcher-Kay, Carrie. Depression and Suicide. Peds in Review. Nov 2003; 24:363-370.

2. Committee on Adolescence. Suicide and Suicide Attempts in Adolescents. Pediatrics 2000; 105:871-874.

3. Borowsky, Iris W. Adolescent Suicide Attempts: Risk and Protectors. Pediatrics Mar2001; 107: 485-493.

4. Slap, Gail. Adoption as a Risk Factor for Attempted Suicide During Adolescence. Pediatrics Aug2001; Volume 108.

5. Woods, Elizabeth R. The Associations of Suicide Attempts in Adolescents. Pediatrics June 1997; 99:791-796.

6. Friendman R.A. Uncovering an Epidemic-Screening for Mental Illness in Teens.  NEJM Dec 28, 2006

7. March J. et. al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized control trial.  JAMA 2004;292:807
8. Hammad, TA et. al. Suicidality in pediatric patientts with antidepressant drugs.  Arch Gen Psychiatry 2006;63;332