Childhood and Adolescent Depression and the Risks of Suicide Essay
Childhood and Adolescent Depression and the Risks of Suicide
Problem and its Background
One of the most common reasons for referral of children and adolescents to mental health professionals is suspected depression. There are continues debate as to whether childhood and adolescent depression are a reflection of normal variation in mood. It is reasonable for the primary care physician to view childhood depression as a constellation of factors that forms a syndrome. This constellation consists of a persistent mood disorder and dysfunctional behavior that intrudes and distorts the child’s day-to-day activities (Gottlieb & Williams, 1991 p.1).
A firm denial gave way into a general and strong conviction about significance of depressive syndromes in childhood and adolescents, and of the implications throughout the life course. The realization of the problem occurrence made it possible for the therapeutic interventions and prevention programs to be developed and set up for depressive children, and to have these programs sponsored and evaluated on a scientific perspective. Various factors have facilitated the progression of this study concerning the recognition of childhood depression. Society is approached with enormous cost of untreated childhood depression later on in life (Corveleyn etal, 2005 p.165).
The concept of a depressive syndrome that is distinct from the broad class of childhood onset emotional disorders has been linked to incidence of suicidal rates worldwide. The condition of such incidence is becoming evidently alarming as the number of suicidal rate continue.
The treatment of such depressive states range from pharmacologic drugs up to psychological modifications and therapies, such as behavioral, peer and group focused groups, etc. With the serious nature of childhood / adolescent depression, it is crucial that treatments with known efficacy and more than transitory effects be provided promptly and skillfully (Maj & Sartorius, 2002 p.292).
Scope and Limitations
The treatment procedures and the condition of health care management for the case of childhood and adolescent depression are the primary subjects of the study. The concept on treatment procedure involves the pharmacologic, medical and psychological interventions that are absolutely necessary in the health care management of such condition. The study shall cover the discussion of depressive condition of the childhood and adolescent age group.
Diagnostic procedures and issues shall be tackled in this research in order to portray possible conflicts and difficulties that occur in diagnosing the condition. The neurobiology of the depressive state shall be elaborated utilizing psychophysiology of the disorder, and linked to probable external physiological occurrences. Lastly, since the study focuses on therapy and medication as treatment modalities, the following methods and means of treatment shall be involved in the study. The following shall be the objectives of the over-all study.
- To be able to define, discuss and elaborate the conditions involved in the occurrence of depression in adolescent and childhood stages
- To be able to provide and tackle the treatment procedure as the center scope of study, accompanied by the issues, physiology and specific drugs involved in depression health care management.
Cases of despondency and depression in children and adolescents were reported as early as the seventeenth century. Prior to the 1970s, however, little attention was paid to depression in youth (Hersen & Hasselt, 2001 p.243). The study on depression had been more inclined to adulthood depression and not on childhood and adolescence.
Depression among children and adolescents is relatively common, enduring, and recurrent disorder that has an adverse impact on a youngster’s psychosocial development and in some cases is associated with self-destructive and life-threatening behaviors.
Depressive disorders during childhood and adolescence may be more virulent and of longer duration than depressive disorders in adults. Depressive disorders during childhood are a risk factor for the development of additional psychological disturbances and for the development of depressive disorders later in life. The number of youths who are experiencing depressive disorders is increasing at the same time that the age of onset is decreasing (Mash & Barkley, 2006 p.336).
Depression can be conceptualized both as a dimension and as a category. Epidemiological studies suggest that juvenile depression is a continuum that is associated with problems at most levels of severity. According to Oregon Adolescent Depression Project, the level of psychosocial impairment increased as a direct function of the number of depressive symptoms. Moreover, in line with studies of adults, much of the morbidity associated with depression occurred in the “milder” but more numerous cases of minor depression. Such results suggest that even mild forms of adolescent depression are a risk factor for depression in early adulthood (Rutter & Taylor, 2002 p.463).
In recent years, increased attention has been given to evidence-based psychosocial and pharmacological interventions for depressed youth. The need to highlight what we know about treatment is underscored by the fact that most depressed youth do not receive treatment. However, as knowledge about treatments for youth depression has increased, the rate of treatment appears to have developed. Although depression among youth is treated more often, it is not clear that standard practice is effective at alleviating depressive symptoms or preventing recurrence. Moreover, there is a bias toward the utilization of pharmacologic drugs and extremely brief psychosocial interventions (Gotlib & Hammen, 2002 p.441).
Diagnostic Issues involved in Depression
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision groups mood disorders into two categories: depressive disorders and bipolar disorders. Both types of disorders are characterized by depressive episodes. For a diagnosis of depressive disorder, the child must be experiencing a mood disturbance for a period of at least 2 weeks, and the symptoms must be present more often than not. At least four of the following symptoms must be present during the same period (Mash & Barkley, 2006 p.337):
- Significant, unintentional weight gain or loss
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
- fatigue or loss or energy
- feelings of worthlessness or extreme guilt
- Diminished concentration pr ability to make decisions
- Recurring thoughts of death, suicidality, or suicide attempts
In depressed preadolescents and adolescents, a lack of perceived personal competence was associated with depression; however, in adolescents, the more abstract concept of contingencies is also related to depression (Mash & Barkley, 2006 p.338).
Confusion sometimes arises in the childhood depression field, as it does with adult depression, because of different usages of the term “depression” and associated differences in methods of assessment. Moreover, the Diagnostic and Statistical Manual of Mental Disorders, which is the primary reference of psychiatric diagnosis, frequently changes.
One example is in studies of childhood and adolescent depression, the term is variously used to identify depressed mood, a constellation of mood and other symptoms forming a syndrome, or a set of symptoms meeting official diagnostic criteria for depressive disorder. The usage of such term connotes various meaning, such as depression as a symptoms (lonely, fear impulses, guilt, etc.) and depression as a syndrome (comprises clusters of various signs and symptoms) (Mash & Barkley, 2003 p.336).
Neurobiology of Childhood & Adolescent Depression
Biologic studies in children are difficult to implement since they often require several blood draws, subjects remaining still more long periods of time, and the overall cooperation of the children and adolescents. Three types of investigation have provided information on possible developmental differences in the neurobiology of depression. The first is the study of Cortisol secretion, measured by investigations such as the dexamethasone suppression test (Rapoport, 2000 p.230).
Studies of neurotransmitters in depressed adults have focused on norepinephrine, serotonin, and acetylcholine. Serotonin regulation studied in adults with depression reported that in response to L-5hyroxytrytophan in 37 pre-pubertal depressed children secreted less Cortisol and more prolactin than age-matched and gender-matched normal controls, suggesting a deregulation of central serotonergic systems in childhood depression.
Abnormalities of the hypothalamic pituitary-thyroid axis and the hypothalamic pituitary-growth hormone axis have been reported in depression in adults. However, Cortisol hypersecretion, as measured by repeated samples over a 24-hour period or by nocturnal sampling, has not been identified in depressed children and adolescents although adolescent showed a Cortisol elevation at the approximate time of sleep onset (Coffey, 2006 p.266).
The second type of developmentally informative investigation is the study of sleep. Polysomnographic studies of depressed children and adolescent have tended to demonstrate abnormalities of sleep, including shortened rapid eye movement (REM) latency and reduced slow wave sleep. These generally positive results of polysomnographic studies with children have shown few differences (Rapoport, 2000 p.231).
The third type of developmentally informative investigation is the study of growth hormone. A variety of pharmacological challenge agents that stimulate release of growth hormone have been studied in depressed adolescents and children. Interestingly, the results with adolescents have been negative in terms of slow blunted growth hormone response to provocative stimuli. However, some studies have reported high levels of growth hormone in adolescents with major depression. Moreover, pubertal children both during depressive episode and after recovery have demonstrated blunted growth hormone response to provocative stimuli (Rapoport, 2000 p.231).
Psychopharmacology: Antidepressants (SSRIs)
Special considerations arise in treating children and adolescents with antidepressants. Empirical data on antidepressants in young patients are quite limited. Psychiatrists, faced with depriving children of potentially effective medication or prescribing medication or prescribing medications “Off Label,” need information on which to base treatment decisions, and efforts are underway to promote research in this area. Clinically significant differences in pharmacokinetics and possibly pharmacodynamics between adults and younger patients can also complicate treatment. Moreover, younger patients may also be more sensitive to adverse effects of medications (Preskorn, 2004 p.356).
The antidepressant drugs are a heterogeneous group of compounds that, in adults, have bee found to be effective in the treatment of major depressive disorder. This particular pharmacologic intervention is also utilized in adolescent and children with major depression; although, there have been no studies that validate the appropriateness of such medications.
The following are considered as the major treatment of adolescent depression, specifically Tricyclic Antidepressants and (SSRI) Selective-serotonin reuptake inhibitors (Rossenberg & Ryan, 1998 p.28).
Tricyclic antidepressants (TCAs) have long been the first-line antidepressants used by most clinicians for adults because of their established efficacy, safety, and ease of administration, but they have been less successful in the treatment of child and adolescent conditions. The mechanism by which TCAs are effective in the treatment of adult depression and other disorders has not been clearly established. There is, however, evidence that these agents affect monoamine neurotransmitter systems in the central; nervous system, such as serotonin and norepinephrine (Rossenberg & Ryan, 1998 p.28-29).
The TCAs inhibit the reuptake of norepinephrine and serotonin, potentiating their action. It has been suggested that antidepressants work by increasing noradrenergic and/or serotonergic transmission, compensating for a presumed deficiency. Controlled studies failed to demonstrate that TCAs are superior to placebo in the treatment of childhood and adolescent depression (Rossenberg & Ryan, 1998 p.28-29).
Since serotonin is also implicated in the etiology and maintenance of affective disorders, particularly depression; hence, the use selective serotonin reuptake inhibitor (SSRIs) is possible. SSRIs prevent the re-uptake of serotonin, which poses significant therapeutic value although has been shown to be less effective in therapeutic trials in children (Mash & Barkley, 2006 p.384).
The SSRIs are now first-line agents for treating child and adolescent depression. The newer antidepressants, such as bupropion and mirtazapine, do not have an adequate empirical base with children; however, they are sometimes used as second-line treatments for those youths who do not respond to SSRIs. Thus far, none of the SSRIs has produced irreversible damage in children and adolescents. However, as the SSRIs gained wide use with depressed adolescents, concerns emerged about the safety of this class of medications. Reports suggested that they were responsible for increased suicidal ideation and behavior among youths (Mash & Barkley, 2006 p.384).
In 2003, the British Medicines and Healthcare products Regulatory Agency (MHRA) concluded that most of the SSRIs do not show benefits exceeding their risks of suicidal ideation, and thus should not be prescribed in the child and adolescent population (Mash & Barkley, 2006 p.384).
If the adolescent fails to respond to any SSRI, then switching to a different class of antidepressant is recommended. At present, no data support the use of one agent over another. Therefore, whether the clinician chooses a TCA, nefazodone, or venlafaxine should be based on clinical experience. Other factors to consider for a given adolescent are medication side effects, medical conditions, previous medication trials, comorbid psychiatric conditions, and familial history of a positive response to particular antidepressants (Esman, 1999 p.222). Other classes of antidepressants are fluoxetine, setraline, paroxetine, fluvoxamine, venlafaxine, bupropion, trazodone, and nefazadone.
As major depression has a high recurrence rate, it is recommended that pharmacologic treatment continue for a minimum of six months achieving resolution of symptoms. Medication discontinuation should be accomplished gradually, with a slow, stepwise reduction in dosage over a two- or three-month period. The health care providers should carefully monitor the adolescent for withdrawal syndromes and reemergence of depressive symptoms (Esman, 1999 p.222).
Relationship to Suicide Rates
Suicidal thoughts and attempts are among the diagnostic criteria for major depression. Suicidal ideation is quite common, and has been reported in more than 60% of depressed preschoolers, preadolescents, and adolescents. Actual suicidal attempts also may occur, at rates that appear to be higher among depressed adolescents than among depressed adults (Mash & Barkley, 2003 p.336).
Studies have shown consistently high rates of comorbid psychiatric disorders in depressed children and adolescents. The comorbidity rate in children and adolescents with depression has been reported to be 80% to 95%. The most common comorbid disorders in adolescents with depression are anxiety disorders, with rates ranging from 40% to 50%. Moreover, substance abuse frequently co-occurs with depression.
Adolescents with major depression are at risk for impairment in school performance and interpersonal relationships, which may interfere with achievement of appropriate developmental tasks. Suicidal behavior is a common sequela. A 10-yar follow-up of depressed child and adolescent outpatients found that 4.4% committed suicide. Mood disorder, prior to suicide attempt, and substance abuse are major risk factors for adolescent suicide (Esman, 1999 p.216).
Depressed and suicidal children and adolescents are often not identified. Identification of children and adolescents who express suicidal ideation or suicidal acts is crucial since such symptoms are recurrent and strong predictors of youth suicide. Other risk factors for youth suicide behavior have been described including family, other environmental and biological factors. Notably, family history of suicidal behavior increases risk for youth suicide (Rapoport, 2000 p.231).
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Esman, A. H. (1999). Adolescent Psychiatry: Developmental and Clinical Studies. Routledge.
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Maj, M., & Sartorius, N. (2002). Depressive Disorders. John Wiley and Sons.
Mash, E. J., & Barkley, R. A. (2006). Child Psychopathology. Guilford Press.
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Preskorn, S. (2004). Antidepressants: Past, Present, and Future. Springer.
Rapoport, J. L. (2000). Childhood Onset of “Adult” Psychopathology: Clinical and Research Advances. American Psychiatric Pub., Inc.
Rossenber, D., & Ryan, N. (1998). Pocket Guide for the Textbook of Pharmacotherapy for Child and Adolescent Psychiatric Disorders. Psychology Press.
Rutter, M., & Taylor, E. A. (2002). Child and Adolescent Psychiatry. Blackwell Publishing.
University/College: University of California
Type of paper: Thesis/Dissertation Chapter
Date: 20 March 2017
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