Depression in Young People

These are notes taken about a webinar by the National Institute of Mental Health. This is a review of everything talked about during the webinar. 

Why is there Depression?

Sadness and depression can be an evolutionary protection device from negative outcomes. It may be a physic pain or a way of changing one's environment. There may be positivity to negativity. It may be a protection from infections or how we focus on the past (an analytical rumination of thinking).

Is this sadness or depression? For about 3 weeks, a girl named Christina's mood is low, she spends her time alone. Her grades are lowering and she cannot concentrate. Her parents separated very recently.

Five of the following symptoms are present for two or more weeks:

Depressed mood for most of the day, or irritable mood, it has to be present most of the time
Markedly diminished interest or pleasure at all
Significant change in weight when not dieting or weight gain
Insomnia or Hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
Diminished ability to think or concentrate
Recurrent thoughts of death (not just fear of dying) recurrent suicidal ideation without a specific plan or an attempt or specific plan to commit suicide

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Prevalence

10-17% In adults
1-2% in pre-pubertal children
Adolescents with depression are 30% more likely to die of suicide
In its severe form, it affects 9% of adolescents
Second leading cause of people living with disability
More prevalent than other diseases, even cancer

Genes and Environment: Potential Causes

Genes: 30-50% of the liability to depression
Gene-environment correlation: e.g. Increased genetic liability for lifetime traumas
Gene-environment interaction: different genotypes respond to environmental variability in different ways

Ex. Christina's mother is diagnosed with depression during pregnancy. It may pass down to the child. Christina's father lives far away and sees her rarely. He drinks and his company went bankrupt. Since Christina shares genes with both of these people, she has a higher liability in having depression. They also experienced traumatic events, which may affect her more. But since they are correlated, they may end up working together passively or actively. Ex: Since Christina's mother is depressed, they may both become depressed since they share the same genes and experiences.

Dr Kendler used a study on identical and fraternal twins to see how much environment affects liability. Having a traumatic life event increases the chances dramatically. The lowest chances are the ones with genetics that don't react as strongly. The opposite leads to a higher chance of depression in the presence of a life event. So some people may have completely different reactions to the same event.

With the onset of puberty, girls are more likely to have depression than boys. There is a 1 to 2 ratio. It may have to do to with cognitive processing, greater exposure to psychological stressors, or hormonal mechanisms. Girls with an earlier start in their menstrual cycle are more likely to become depressed, it may be because of hormones, or a psychological stressor, or over exposure to other people, they feel uncomfortable around.

There is a debate on whether childhood depression correlates with adult depression, but adolescent depression has shown pathways to adult depression.
Anxiety: early on anxiety precedes depression
Alcohol: Probably an "internalising" way of handling depression
ODD/CD: The strongest predictors for later depression
Behaviour problems and depression are related
40% had disruptive behaviour in their childhood
Highest risk in girls
Youth with CD are twice more likely to have it
Irritable and disruptive behaviour are shown to be directly correlated. What we need to find out is how this transition starts and finding out who has depression and who doesn't.

Depression is a heterogeneous syndrome. It is useful to think of two abnormalities

-Negativity bias and missing the positive
It is more common for someone with anxiety or depression to misinterpret a neutral face as sad or angry.
-They will pick up what is negative in their environment
They will be more likely to miss the positive, such as a smile. A depressed person will relate a smile back to positive less than someone else. Anti-depressants work highly in these areas.
Motivation and reward processing
-Most people go after rewards and feel good when they get it
Anticipatory anhedonia: People with depression will not take the effort to get that reward
People will see this as lazy or a motivation problem, but with depression, it is more that the person can't see why this would be important
Ex: Christina used to dance, but she stopped because they are "no fun at all" She has stopped sending texts to her friends.
People with no processing in the longitudinal segment of the brain are more likely to be depressed in life; this is the segment of the brain that has reward processing.

Phycological and Medical Treatments

Christina's diagnosis was delayed for 18 months. Why?
Parents focused on irritability/oppositionality
Teachers focused on academic performance
She herself could not talk about it, except in terms such as "boring", "annoying" etc.
She was only diagnosed after she took her first overdose and then it became apparent that she had been "cutting" for a while.
It was still hard to explain to her parents the meaning of the problem
She herself was still perplexed

Awareness is key to diagnosis.
Screening is only appropriate in samples that are at high risk. Screening can range from single questions to a questionnaire. Diagnosis should also address the presence of manic symptoms, underlying medical causes (rare), risk assessment, such as past attempts of suicide and cases of depression. They shouldn't have access to guns or drugs.

Not all causes are changeable, such as environment or genes. You may be able to change the relationship between the mother and child or the father and child. Medication can have an effect on behaviour, feelings, and thoughts through the brain, but so does psychological treatments.

The first treatment is a reuptake in serotonin, fluoxetine, sertraline, citalopram
Psychological treatments such as interpersonal treatment or cognitive therapy

There haven't been any sign that one is better than the other. In mild cases, start with CBT/IPT
Some studies show that using them both may be the best
About 60% of young people respond to an antidepressant, however, 50% respond to placebo. This may be related to the severity of the depression, the higher the severity of the depression, the lower they affect to placebo.
The numbers needed to treat a person are 10 and the numbers needed to harm is 112. This is particularly important in the context of suicidality debate and the black box warning.