Practice parameter for the assessment and treatment of children and adolescents with depressive disorders

The Relationship between Flourishing and Depression in Children in the U.S. Using a Socioecological Perspective

Children's flourishing is likely to be associated with achieving a positive mental and physical quality of life, which is considered as an important factor for helping children to overcome psychological adversity during the critical stage of emotional development. This study examined the relationships between children's flourishing and childhood depression. This was a cross-sectional study using the 2011-2012 National Children's Health Survey in the U.S. The conceptual framework that guided this study was a modified ecological system theory model. Multiple regressions were performed to investigate the associations between flourishing and pediatric depression, controlling for demographics, physical activity-related behaviors, family and environmental conditions. A total of 45,309 children (representing 33,293,823 children at the population level) were identified in this study (mean age: 13.63 years; female: 48.7%). Children's childhood depression was highly related to direct parenting functions, individual needs and environmental availabilities and accessibilities from a socioecological perspective. This study revealed multiple dimensions of how sociological factors influence children's flourishing and mental health. Parents' involvement in children's physical activities and family and social support are crucial for children's flourishing and mental health status. More attention needs to be paid to provide children with family and social support to help them to overcome and reduce childhood depression.

The relationship of severity of depression with homocysteine, folate, vitamin B12, and vitamin D levels in children and adolescents

BACKGROUND

Depression is a heterogeneous disorder and is thought to develop as a result of complex interactions between genetic and environmental factors. One-carbon metabolism that includes vitamin B12, folic acid, and homocysteine has been investigated in psychiatric disorders like depression. In recent years, vitamin D has also been considered to contribute to psychiatric disorders. In this study, serum levels of folate, vitamin B12, and homocysteine related to one-carbon metabolism and vitamin D were investigated in children and adolescents with depression and to assess possible roles in depression pathogenesis.

METHODS

The study included 89 children and adolescents with depression (69 female, 20 male; mean age ± SD = 15.08 ± 1.46) and 43 control subjects (31 female, 12 male; mean age ± SD = 14.41 ± 2.32) without any DSM-5 diagnosis. Each subject completed a sociodemographic form, Childhood Depression Inventory, State-Trait Anxiety Inventory 1-2 and measured serum folate, vitamin B12, homocysteine, and 25-OH vitamin D levels.

RESULTS

There was no significant difference between the groups in terms of folate levels (p = .052). In the patient group, the vitamin B12 and vitamin D levels were clearly low (p values for both levels were <.001), while homocysteine levels were found to be remarkably high (p < .001). In addition, there was a negative correlation between depression severity and vitamin B12 and vitamin D, while a positive correlation was found with homocysteine.

CONCLUSIONS

The results of the study show that vitamin B12 deficiency or insufficiency and elevated homocysteine may contribute to the etiopathogenesis of depression. Additionally, it was shown that lower vitamin D levels may be associated with depression.

KEY PRACTITIONER MESSAGE

Depression of children and adolescents is associated with the interaction of environmental and genetic factors. Homocysteine, vitamin B12, and folate related to one-carbon metabolism are associated with psychiatric disorders such as depression in adulthood. Vitamin D also contributes to psychiatric disorders pathogenesis. There are not enough studies in the literature about these parameters in children with depression. Low vitamin B12 and vitamin D levels and increased homocysteine levels may play a role in the pathogenesis of depression in children and adolescents. Investigation of vitamin B12, folate, homocysteine, and vitamin D levels are recommended in children and adolescents with depression.

Suicide assessment and treatment in pediatric primary care settings

TOPIC

This article will briefly review screening for depression and suicidal ideation in primary care and school-based clinics, with a focus on in-depth screening for imminent suicide risk, developing a safety plan, and incorporating handoffs to urgent and emergency mental health care personnel. The article will cover current definitions of levels of suicidal risk and clinic-based protocols for a team approach to adolescents in crisis.

PURPOSE

To provide primary care and behavioral health nurses with evidence-based suicide risk screening and assessment tools and best practices for using them in patient-centered encounters with adolescents with suicidal thinking or behavior.

SOURCES USED

Journal articles, books, and reports.

CONCLUSION

Past studies have shown that many individuals who died by suicide had seen a primary care provider in 30 days before their deaths. Nurses in primary care settings should develop clinic-based protocols for screening all adolescents for suicide risk, developing safety plans, and providing suicidal youth and families with monitoring, appropriate referrals, follow-up, and support.

Study Protocol for Teen Inflammation Glutamate Emotion Research (TIGER)

This article provides an overview of the study protocol for the Teen Inflammation Glutamate Emotion Research (TIGER) project, a longitudinal study in which we plan to recruit 60 depressed adolescents (ages 13–18 years) and 30 psychiatrically healthy controls in order to examine the inflammatory and glutamatergic pathways that contribute to the recurrence of depression in adolescents. TIGER is the first study to examine the effects of peripheral inflammation on neurodevelopmental trajectories by assessing changes in cortical glutamate in depressed adolescents. Here, we describe the scientific rationale, design, and methods for the TIGER project. This article is intended to serve as an introduction to this project and to provide details for investigators who may be seeking to replicate or extend these methods for other related research endeavors.

Utility of oxcarbazepine in the treatment of childhood and adolescent psychiatric symptoms

The primary aims of this study were to determine if oxcarbazepine is a safely tolerated option for treatment of psychiatric symptoms in children and whether its use facilitates dose modification of other psychotropic medications. A retrospective chart review was completed using data extracted from the electronic medical record of a large outpatient child psychiatry clinic. A total of 507 of 740 children prescribed oxcarbazepine for psychiatric indications for 3 months or more had adequate data to assess clinical responses and medication outcomes. Most patients prescribed oxcarbazepine experienced clinically significant control of irritability/anger, mood stabilization, aggressive outbursts, impulsivity, or anxiety, with over 80% achieving at least maintenance symptom control. In all, 51% and 25% fully discontinued second- or third-generation antipsychotic or antidepressant medication, respectively, after starting oxcarbazepine; 8% discontinued oxcarbazepine for nonresponse, while 9% stopped oxcarbazepine because of emergent side effects. In patients fully discontinuing or reducing the second- or third-generation antipsychotic dose by 50% or more, improvements in body mass index were observed. Oxcarbazepine may prove to be an appropriate alternative to antipsychotic and antidepressant medications for treating psychiatric symptoms in children and adolescents. In particular, it may be a more metabolically neutral psychotropic medication.

Depression in adolescence: a review

Background

Depression is a common mental health disease, especially in mid to late adolescence that, due to its particularities, is a challenge and requires an effective diagnosis. Primary care providers are often the first line of contact for adolescents, being crucial in identifying and managing this pathology. Besides, several entities also recommend screening for depression on this period. Thus, the main purpose of this article is to review the scientific data regarding screening, diagnosis and management of depression in adolescence, mainly on primary care settings.

Main body

Comprehension of the pathogenesis of depression in adolescents is a challenging task, with both environmental and genetic factors being associated to its development. Although there are some screening tests and diagnostic criteria, its clinical manifestations are wide, making its diagnosis a huge challenge. Besides, it can be mistakenly diagnosed with other psychiatric disorders, making necessary to roll-out several differential diagnoses. Treatment options can include psychotherapy (cognitive behavioural therapy and interpersonal therapy) and/or pharmacotherapy (mainly fluoxetine), depending on severity, associated risk factors and available resources. In any case, treatment must include psychoeducation, supportive approach and family involvement. Preventive programs play an important role not only in reducing the prevalence of this condition but also in improving the health of populations.

Conclusion

Depression in adolescence is a relevant condition to the medical community, due to its uncertain clinical course and underdiagnosis worldwide. General practitioners can provide early identification, treatment initiation and referral to mental health specialists when necessary.

Measurement-Based Care in the Treatment of Adolescent Depression

Measurement-based care is a helpful adjunct to clinical assessment in improving outcomes in depression in adults and adolescents. Measurement-based care principles are incorporated in current regulatory requirements for use of standardized instruments in efforts to improve care and prevent suicide. Challenges for child and adolescent psychiatrists and other clinicians in implementing measurement-based care include concerns about time and expense involved in administration and interpretation of results from rating scales and other instruments. Implementation can be facilitated by selection of instruments that are brief, easy to administer and score, compatible with electronic health record systems, and available in the public domain.

Treatment of mental illness in American adolescents varies widely within and across areas

Many mental health disorders first manifest in adolescence, and early treatment may affect the course of the disease. Using a large national database of insurance claims, this study focuses on variations in the type of care that adolescent patients receive when they are treated for an initial episode of mental illness. We found large variations in the probability that children receive follow-up care and in the type of follow-up care received across zip codes. We also found large variations in the probability that children receive drug treatments that raise a red flag when viewed through the lens of treatment guidelines: Overall, in the first 3 mo after their initial claim for mental illness, 44.85% of children who receive drug treatment receive benzodiazepines, tricyclic antidepressants, or a drug that is not Food and Drug Administration-approved for their age. On average, these children are 12 y old. While the supply of mental health professionals impacts treatment choices, little of the overall variation is explained by supply-side variables, and at least half of the variation in treatment outcomes occurs within zip codes. These results suggest that other factors, such as physician practice style, may play an important role in the types of treatment that children receive.

Critical appraisal of clinical practice guidelines for depression in children and adolescents: A protocol for systematic review

BACKGROUND

Depression as a clinically significant and growing public health issue is the third leading cause of disability. Adolescent-onset depression has been associated with psychiatric, anxiety disorders, suicidality, medical comorbidities, and an elevated risk of major depressive disorder episodes later in life. How to effectively identify, prevent, and treat depression has become one of the key points of discussion among medical institutions/departments. With the importance of depression being emphasized, countries/organizations around the world have developed guidelines for clinical practice related to depression for different groups of people to guide medical staff to implement scientific, effective, and standardized depression management. However, the quality of such guidelines is not yet clear, which is not conducive to the selection of medical staff and affects clinical application to a certain extent. This study aims to evaluate the rigor of the development of clinical practice guidelines (CPGs) for depression in children and adolescents and will identify, in these documents, the recommendations for depression in children and adolescents.

METHODS

Electronic databases and specific databases of CPGs will be searched. Study selection and data extraction will be performed independently by 2 reviewers. The AGREE II Instrument and RIGHT checklist will be used to assess the methodological quality and reporting quality of included CPGs about depression in children and adolescents. We will also analyze consistency and inconsistency of the recommendations in CPGs, including assessment, diagnosis, screening, treatment, and management. Bubble charts will be used to show the differences in methodological and reporting quality. Subgroup analysis will be conducted according to the result of evaluation. Excel and Endnote X9 will be used.

RESULTS

Using the search drafts of electronic databases, we included 6 CPGs. The results of our study will be published in a peer-reviewed journal.

CONCLUSIONS

Our study will provide systematic evidence for existing CPGs for depression in children and adolescents and provide a guidance for CPGs users.

PROTOCOL REGISTRATION

INPLASY202080002.

Effectiveness and moderators of individual cognitive behavioral therapy versus treatment as usual in clinically depressed adolescents: a randomized controlled trial

We examined if manualized cognitive behavioral therapy (CBT) was more effective than Treatment As Usual (TAU) for clinically depressed adolescents within routine care. This multisite Randomized controlled trail included 88 clinically depressed adolescents (aged 12-21 years) randomly assigned to CBT or TAU. Multiple assessments (pre-, post treatment and six-month follow-up) were done using semi-structured interviews, questionnaires and ratings and multiple informants. The primary outcome was depressive or dysthymic disorder based on the KSADS. Completers, CBT (n = 19) and TAU (n = 26), showed a significant reduction of affective diagnoses at post treatment (76% versus 76%) and after six months (90% versus 79%). Intention-to-treat analyses on depressive symptoms showed that 41.6% within CBT and 31.8% within the TAU condition was below clinical cut-off at post treatment and after six-months, respectively 61.4% and 47.7%. No significant differences in self-reported depressive symptoms between CBT and TAU were found. No prediction or moderation effects were found for age, gender, child/parent educational level, suicidal criteria, comorbidity, and severity of depression. We conclude that CBT did not outperform TAU in clinical practice in the Netherlands. Both treatments were found to be suitable to treat clinically referred depressed adolescents. CBT needs further improvement to decrease symptom levels below the clinical cut-off at post treatment.

Harnessing Mental Imagery and Enhancing Memory Specificity: Developing a Brief Early Intervention for Depressive Symptoms in Adolescence

Background

Treatment innovation for depressive symptoms in adolescence is urgently needed. Adult research suggests interventions targeting underlying cognitive mechanisms, such as dysfunctional mental imagery and overgeneral memory, are promising. Here, we describe and evaluate in a case series a brief imagery-based intervention for depressive symptoms that targets these cognitive mechanisms.

Methods

Nine participants completed the four-session intervention, whose principle components were imagery rescripting and memory specificity training. Questionnaires and experimental tasks (assessing symptomatology and cognitive mechanisms) were administered at three time points: pre-intervention, post-intervention and 3-month follow-up.

Results

The intervention was feasible to deliver and acceptable to participants. There was a large reduction in depression symptom scores from pre to post intervention (d = 1.32; 67% showed reliable improvement, RI) and this was maintained at follow-up (d = 1.46; RI = 75%). There were also reductions in anxiety (post: d = 1.15, RI = 44%; follow-up: d = 1.67, RI = 63%), increases in self-esteem (post: d = − 0.70, RI = 44%; follow-up: d = − 1.20, RI = 50%) and noteworthy changes in memory specificity (post: d = − 1.80, RI = 67%; follow-up: d = − 0.94, RI = 63%).

Conclusions

This is the first study to use imagery rescripting and memory specificity training in adolescence. Initial evidence is provided that the intervention is acceptable and may have clinical utility. Future randomised controlled trials are needed to further assess the intervention.

A Digital Intervention for Adolescent Depression (MoodHwb): Mixed Methods Feasibility Evaluation

BACKGROUND

Treatment and prevention guidelines highlight the key role of health information and evidence-based psychosocial interventions for adolescent depression. Digital health technologies and psychoeducational interventions have been recommended to help engage young people and to provide accurate health information, enhance self-management skills, and promote social support. However, few digital psychoeducational interventions for adolescent depression have been robustly developed and evaluated in line with research guidance.

OBJECTIVE

We aimed to evaluate the feasibility, acceptability, and potential impact of a theory-informed, co-designed digital intervention program, MoodHwb.

METHODS

We used a mixed methods (quantitative and qualitative) approach to evaluate the program and the assessment process. Adolescents with or at elevated risk of depression and their parents and carers were recruited from mental health services, school counselors and nurses, and participants from a previous study. They completed a range of questionnaires before and after the program (related to the feasibility and acceptability of the program and evaluation process, and changes in mood, knowledge, attitudes, and behavior), and their Web usage was monitored. A subsample was also interviewed. A focus group was conducted with professionals from health, education, social, and youth services and charities. Interview and focus group transcripts were analyzed using thematic analysis with NVivo 10 (QSR International Pty Ltd).

RESULTS

A total of 44 young people and 31 parents or carers were recruited, of which 36 (82%) young people and 21 (68%) parents or carers completed follow-up questionnaires. In all, 19 young people and 12 parents or carers were interviewed. Overall, 13 professionals from a range of disciplines participated in the focus group. The key themes from the interviews and groups related to the design features, sections and content, and integration and context of the program in the young person's life. Overall, the participants found the intervention engaging, clear, user-friendly, and comprehensive, and stated that it could be integrated into existing services. Young people found the "Self help" section and "Mood monitor" particularly helpful. The findings provided initial support for the intervention program theory, for example, depression literacy improved after using the intervention (difference in mean literacy score: 1.7, 95% CI 0.8 to 2.6; P<.001 for young people; 1.3, 95% CI 0.4 to 2.2; P=.006 for parents and carers).

CONCLUSIONS

Findings from this early stage evaluation suggest that MoodHwb and the assessment process were feasible and acceptable, and that the intervention has the potential to be helpful for young people, families and carers as an early intervention program in health, education, social, and youth services and charities. A randomized controlled trial is needed to further evaluate the digital program.

Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children

OBJECTIVE

We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility.

METHODS

We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner).

RESULTS

We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits.

CONCLUSIONS

Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.

Incidence and prevalence of primary care antidepressant prescribing in children and young people in England, 1998-2017: A population-based cohort study

BACKGROUND

The use of antidepressants in children and adolescents remains controversial. We examined trends over time and variation in antidepressant prescribing in children and young people in England and whether the drugs prescribed reflected UK licensing and guidelines.

METHODS AND FINDINGS

QResearch is a primary care database containing anonymised healthcare records of over 32 million patients from more than 1,500 general practices across the UK. All eligible children and young people aged 5-17 years in 1998-2017 from QResearch were included. Incidence and prevalence rates of antidepressant prescriptions in each year were calculated overall, for 4 antidepressant classes (selective serotonin reuptake inhibitors [SSRIs], tricyclic and related antidepressants [TCAs], serotonin and norepinephrine reuptake inhibitors [SNRIs], and other antidepressants), and for individual drugs. Adjusted trends over time and differences by social deprivation, region, and ethnicity were examined using Poisson regression, taking clustering within general practitioner (GP) practices into account using multilevel modelling. Of the 4.3 million children and young people in the cohort, 49,434 (1.1%) were prescribed antidepressants for the first time during 20 million years of follow-up. Males made up 52.0% of the cohorts, but only 34.1% of those who were first prescribed an antidepressant in the study period. The largest proportion of the cohort was from London (24.4%), and whilst ethnicity information was missing for 39.5% of the cohort, of those with known ethnicity, 75.3% were White. Overall, SSRIs (62.6%) were the most commonly prescribed first antidepressant, followed by TCAs (35.7%). Incident antidepressant prescribing decreased in 5- to 11-year-olds from a peak of 0.9 in females and 1.6 in males in 1999 to less than 0.2 per 1,000 for both sexes in 2017, but incidence rates more than doubled in 12- to 17-year-olds between 2005 and 2017 to 9.7 (females) and 4.2 (males) per 1,000 person-years. The lowest prescription incidence rates were in London, and the highest were in the South East of England (excluding London) for all sex and age groups. Those living in more deprived areas were more likely to be prescribed antidepressants after adjusting for region. The strongest trend was seen in 12- to 17-year-old females (adjusted incidence rate ratio [aIRR] 1.12, 95% confidence interval [95% CI] 1.11-1.13, p < 0.001, per deprivation quintile increase). Prescribing rates were highest in White and lowest in Black adolescents (aIRR 0.32, 95% CI 0.29-0.36, p < 0.001 [females]; aIRR 0.32, 95% CI 0.27-0.38, p < 0.001 [males]). The 5 most commonly prescribed antidepressants were either licensed in the UK for use in children and young people (CYP) or included in national guidelines. Limitations of the study are that, because we did not have access to secondary care prescribing information, we may be underestimating the prevalence and misidentifying the first antidepressant prescription. We could not assess whether antidepressants were dispensed or taken.

CONCLUSIONS

Our analysis provides evidence of a continuing rise of antidepressant prescribing in adolescents aged 12-17 years since 2005, driven by SSRI prescriptions, but a decrease in children aged 5-11 years. The variation in prescribing by deprivation, region, and ethnicity could represent inequities. Future research should examine whether prescribing trends and variation are due to true differences in need and risk factors, access to diagnosis or treatment, prescribing behaviour, or young people's help-seeking behaviour.

Mental Health Care for LGBT Youths

Lesbian, gay, bisexual, and transgender (LGBT) youths comprise a diverse population with unique developmental experiences and needs. Many experience some form of anti-LGBT stigma. Although most LGBT youths cope well and are free from mental illness, they are at increased risk for a number of psychiatric and other health problems compared with the general population. These problems include depression, anxiety, suicidality, tobacco and substance use, and disordered eating. These disorders are significant sources of morbidity and mortality and are risk factors for other health problems, including HIV and other sexually transmitted infections. Preliminary evidence suggests the same is true for gender dysphoric youths. The minority stress hypothesis holds that exposure to LGBT-specific stigma causes these disparities among LGBT youth. During the past decade, increasing attention has been devoted to developing evidence-based practice guidelines to address the mental health needs of LGBT youths, with an emphasis on core clinical competencies for practitioners working with this population. This review addresses key principles for mental health promotion and care of LGBT youths. Key resources for clinicians and two clinical vignettes are included.

Depression Preceding Diagnosis of Bipolar Disorder

This paper focuses on depression that precedes an onset of manifest bipolar disorder as early stage bipolar disorder. First, we review how to pragmatically identify the clinical characteristics of patients presenting with an episode of depression who subsequently go on to develop episodes of mania or hypomania. The existing literature shows a strong consensus: accurate identification of depression with early onset and recurrent course with multiple episodes, subthreshold hypomanic and/or mixed symptoms, and family history of bipolar disorder or completed suicide have been shown by multiple authors as signs pointing to bipolar diagnosis. This contrasts with relatively limited information available to guide management of such "pre-bipolar" (pre-declared bipolar) patients, especially those in the adult age range. Default assumption of unipolar depression at this stage carries significant risk. Antidepressants are still the most common pharmacological treatment used, but clinicians need to be aware of their potential harm. In some patients with unrecognized bipolar depression, antidepressants can not only produce switch to (hypo)mania, but also mixed symptoms, or worsening of depression with an increased risk of suicide. We review pragmatic management strategies in the literature beyond clinical guidelines that can be considered for this at-risk group encompassing the more recent child and adolescent literature. In the future, genetic research could make the early identification of bipolar depression easier by generating informative markers and polygenic risk scores.

Efficacy and brain mechanism of transcutaneous auricular vagus nerve stimulation for adolescents with mild to moderate depression: Study protocol for a randomized controlled trial

BACKGROUND

Depression is a common mental illness in childhood and adolescence, with an incidence of 4%-5%; it can lead to impairments in learning and social functioning. Transcutaneous auricular vagus nerve stimulation (taVNS) is a commonly used method of auricular acupuncture point stimulation, which is regarded as an effective treatment for adults with depression. The aim of this study was to investigate the efficacy and mechanism of taVNS for adolescents with mild to moderate depression.

METHODS

This randomized controlled clinical trial will include 120 patients aged 12-16 years, all of whom are diagnosed with mild to moderate depression. Patients will be randomly assigned to a taVNS group and a drug control group (sertraline hydrochloride) at a ratio of 1:1. Patients will be evaluated using the 17-item Hamilton Depression Scale, Hamilton Anxiety Rating Scale, Self-Rating Depression Scale, Self-Rating Anxiety Scale, and Pittsburgh Sleep Quality Index scores at baseline, as well as at the 2nd, 4th, 6th, 8th, and 12th weeks. To investigate the underlying neural mechanisms of taVNS treatment from the perspective of the default mode network, multimodal magnetic resonance imaging (MRI; i.e., structural MRI [sMRI], resting state MRI [rsMRI], and pseudocontinuous arterial spin-labeled [pcASL] MRI) will be used to compare cerebral images among groups. MRI data will also be collected from 40 healthy volunteers to assess whether the participants exhibit normal development of structural and functional components.

DISCUSSION

Depression is the most common mental disorder in adolescence. Drug treatment can improve depression symptoms; however, the side effects of drug treatments are often severe. This study proposes a simple physiotherapy that aims to treat adolescents with mild to moderate depression. The mechanism of taVNS in the treatment of depression will also be investigated. The results of this study will provide evidence to guide the application of taVNS in adolescents with depression.

Suicide among Ethiopian origin soldiers in the IDF - A qualitative view of risk factors, triggers, and life circumstances

BACKGROUND

Ethiopian soldiers in the IDF comprise an at-risk group for suicide. The study investigated the unique characteristics of these soldiers, compared with other suicides in the Israel Defense Forces (IDF).

METHOD

The research group included all (n = 36) male soldiers born an Ethiopian family, who died by suicide during their compulsory military service in the years 1990-2017. The control group included all (n = 55) non-Ethiopian soldiers who died by suicide during their military service in the years 2009-2013. Socio-demographic, military-service, and suicide-related variables were examined.

RESULTS

Logistic regression analysis revealed that risk for suicide among Ethiopian soldiers were being incarcerated in a military prison, belonging to a bereaved family, seniority in the military service, and avoidance of help-seeking (explaining 87.8% of the variance).

DISCUSSION

Ethiopian suicide soldiers have endured heavy environmental pressure, such as financial problems and family bereavement. These circumstances could lead to conflict with the soldier's military service, resulting in absence from service or even imprisonment. When the Ethiopian soldier's distress goes un-expressed in words or actions with others, the psychological crisis signs remain unapparent to those around him, and the risk for eventual suicide is high.

LIMITATIONS

The case analysis did not include retrieving information from family and relatives outside the military but was derived from archived material, collected primarily for legal purposes. This limitation was addressed by assembling objective variables and information collected prior to the suicide, along with post-mortem information collected by mental health personnel in their assessments.

Pre-school mental health disorders: a review

Preschoolers are presenting in increasing numbers to primary care providers and mental health clinics with emotional and behavioural impairment. Preschoolers in the US have the highest rates of school expulsion of all age groups. Because young children are limited in their capacity to convey distress and internal states, impairment is most often expressed behaviourally. Disruptive behaviour, frequently in the form of aggression or dysregulation, is a final common pathway for many disorders in this age group. Tools and training to diagnose pre-school disorders are limited, and while some effective non-medication interventions exist, the evidence base for medication use in this age group is extremely limited. This article reviews approaches to assessing common pre-school disorders including attention deficit hyperactivity disorder (ADHD), disruptive behaviour disorders, anxiety and mood disorders, perceptual disturbances and psychosis, and trauma related disorders. The evidence base for both therapeutic and psychopharmacologic interventions for these disorders is discussed.

Intrinsic neural circuitry of depression in adolescent females

BACKGROUND

Adolescence is characterized by affective and cognitive changes that increase vulnerability to depression, especially in females. Neurodevelopmental models attribute adolescent depression to abnormal responses in amygdala, striatum, and prefrontal cortex (PFC). We examined whether the strength of functional brain networks involving these regions predicts depression symptoms in adolescent females.

METHODS

In this longitudinal study, we recorded resting-state functional connectivity (RSFC) in 174 adolescent females. Using a cross-validation strategy, we related RSFC profiles that included (a) a network consisting of amygdala, striatum, and PFC (within-circuit model), (b) connectivity of this network to the whole brain (extended-circuit model), and (c) a network consisting of the entire brain (whole-brain model) to depression symptoms assessed concurrently and 18 months later.

RESULTS

In testing subsets, the within-circuit RSFC profiles were associated with depression symptoms concurrently and 18 months later, while the extended-circuit and whole-brain model did not explain any additional variance in depression symptoms. Connectivity related to anterior cingulate and ventromedial prefrontal cortex contributed most to the association.

CONCLUSIONS

Our results demonstrate that RSFC-based brain networks that include amygdala, striatum, and PFC are stable neural signatures of concurrent and future depression symptoms, representing a significant step toward identifying the neural mechanism of depression in adolescence.

Mental Health Service Use by Medicaid-Enrolled Children and Adolescents in Primary Care Safety-Net Clinics

OBJECTIVE

Little is known about the role of primary care safety-net clinics, including federally qualified health centers and rural health clinics, in providing mental health services to youths. This study examined correlates and quality of mental health care for youths treated in these settings.

METHODS

Medicaid claims data (2008-2010) from nine states were used to identify youths initiating medication for attention-deficit hyperactivity disorder (ADHD) (N=6,433) and youths with an incident depression diagnosis (N=13,209). The authors identified youths who received no ADHD or depression-related visits in a primary care safety-net clinic, some (but less than most) visits in these clinics, and most visits in these clinics. Using bivariate and regression analyses, they examined correlates of mental health treatment in these settings and whether mental health visits in these settings were associated with quality measures.

RESULTS

Only 13.5% of the ADHD cohort and 7.2% of the depression cohort sought any ADHD- or depression-related visits in primary care safety-net clinics. Residence in a county with a higher (versus lower) percentage of residents living in an urban area was negatively associated with receiving the majority of mental health visits in these settings (p<0.05). Compared with youths with no visits in these settings, youths who received most of their mental health treatment in these settings received lower-quality care on five of six measures (p<0.01).

CONCLUSIONS

As investment in the expansion of mental health services in primary care safety-net clinics grows, future research should assess whether these resources translate into improved mental health care access and quality for Medicaid-enrolled youths.

Screening efficiency of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in Swedish help seeking outpatients

BACKGROUND

To evaluate screening efficiency and suggest cut-offs for parent and child Mood and Feelings Questionnaire (MFQ) and the short version (SMFQ) in unselected help seeking child- and adolescent psychiatric outpatients for subgroups of 6-12 versus 13-17 year olds and boys versus girls.

METHOD

Eligible for inclusion were newly admitted outpatients age 6-17 years (n = 5908) in four Swedish child- and adolescent psychiatry clinics. They were prompted consecutively and n = 307 accepted a specific day for assessment until time slots randomly were filled. We prospectively validated the MFQ (33 items) and SMFQ (13 items) in patients (n = 186) using receiver operating characteristics against a reference test of Longitudinal Expert All Data DSM-IV depression based on a Kiddie-Schedule for Affective Disorders and Schizophrenia and 1.2 (sd .6) years of follow-up.

RESULTS

A depressive disorder was confirmed in 59 (31.7%) patients ranging from 14.0% for girls 6-12 years to 53.3% for girls 13-17 years. SMFQ performed roughly equivalent to MFQ. Adolescent score on SMFQ discriminated fairly for boys with Area Under Curve .77 (95% confidence interval .59-.81) and good (.82, .69-.91) for girls and parent ratings for adolescent girls (.85, .73-.93), but not for boys. Depression in children below age 13 could not be discriminated by MFQ or SMFQ whether filled in by child and mostly also when filled in by parent. Favouring maximum kappa value, the optimal cut-off was for MFQ self-report girls ≥32 versus boys ≥11 and for SMFQ self-report girls ≥17 versus boys ≥ 6. Suggested clinical SMFQ cut-offs for girls were ≥12 and for boys ≥ 6.

CONCLUSIONS

MFQ and SMFQ can, with gender-based cut-offs, be used for screening in clinical populations of adolescents but not in children. Parent MFQ and SMFQ can be used for adolescent girls but not boys. SMFQ is sufficient for screening.

Early changes of serum BDNF and SSRI response in adolescents with major depressive disorder

BACKGROUND

Recent evidence suggests that brain-derived neurotrophic factor (BDNF) levels and their early changes may predict antidepressant response in adults with major depressive disorder (MDD). However, in adolescents, BDNF levels in depression and their changes during antidepressant treatment are relatively unknown. We aimed to investigate whether pre-treatment BDNF levels and their early changes predict antidepressant response in depressed adolescents.

METHODS

The study included 83 MDD adolescents and 52 healthy controls aged 12 to 17 years. All depressed adolescents were treated with escitalopram in an 8 week, open-label trial. Depression severity and serum BDNF level at baseline, and weeks 2 and 8 were measured with the Children's Depression Rating Scale-Revised (CDRS-R) and ELISA, respectively.

RESULTS

Responders showed a significant decrease in BDNF levels at week 2 but non-responders and healthy controls had no changes in BDNF levels at week 2. The early decrease (baseline - week 2) of BDNF levels predicted SSRI response with moderate sensitivity and specificity. Logistic regression analysis revealed that early BDNF decrease predicted SSRI response at week 8 after controlling for other demographic and clinical variables.

LIMITATIONS

The follow-up duration of the study was limited in 8 weeks. It remains possible that serum BDNF levels would have changed with longer treatment.

CONCLUSIONS

This is the first longitudinal study to investigate the effect of antidepressants on BDNF levels in adolescents with MDD. Our findings suggest that a decrease of serum BDNF levels in early phase of SSRI treatment may be associated later SSRI response in adolescents with MDD.

Medications for sleep disturbance in children and adolescents with depression: a survey of Canadian child and adolescent psychiatrists

BACKGROUND

Primary care physicians and child and adolescent psychiatrists often treat sleep disturbances in children and adolescents with mood disorders using medications off-label, in the absence of clear evidence for efficacy, tolerability and short or long-term safety. This study is the first to report Canadian data about prescribing preferences and perceived effectiveness reported by child and adolescent psychiatrists regarding medications used to manage sleep disturbances in children and adolescents with depression.

METHODS

Canadian child and adolescent psychiatrists were surveyed on their perception of effectiveness of a range of medications commonly prescribed for sleep disturbances, their ranked preferences for these medications, reasons for avoiding certain medications, and perceived side effects.

RESULTS

Sixty-seven active child and adolescent psychiatrists completed the survey. Respondents reported noting significant sleep issues in 40% of all their patients. Melatonin and trazodone were identified as the first treatment of choice by 83% and 10% of respondents respectively, and trazodone was identified as the second treatment of choice by 56% of respondents for treating sleep disturbances in children and adolescents with depression. Melatonin (97%), trazodone (81%), and quetiapine (73%) were rated by a majority of respondents as effective. Doxepin, zaleplon, tricyclic antidepressants, zolpidem, or lorazepam were rarely prescribed due to lack of evidence and/or concerns about adverse effects, long-term safety, suitability for youth, suicidality, and dependence/tolerance.

CONCLUSIONS

Melatonin and certain off-label psychotropic drugs are perceived as being more effective and appropriate to address sleep disturbances in children and adolescents with depression. More empirical evidence on the efficacy, tolerability and indications for using these medications and newer group of sleep medications in this population is needed.

Annual Research Review: Defining and treating pediatric treatment-resistant depression

BACKGROUND

Adolescent major depressive disorder (MDD) is a significant health problem, associated with substantial morbidity, cost, and mortality. Depression is a significant risk factor for suicide, which is now the second leading cause of death in young people. Up to twenty per cent of adolescents will experience MDD before adulthood, and while a substantial proportion will improve with standard-of-care treatments (psychotherapy and medication), roughly one third will not.

METHODS

Here, we have reviewed the literature in order to discuss the concept of treatment-resistant depression (TRD) in adolescence, examine risk factors, diagnostic difficulties, and challenges in evaluating symptom improvement, and providing guidance on how to define adequate medication and psychotherapy treatment trials.

RESULTS

We propose a staging model for adolescent TRD and review the treatment literature. The evidence base for first- and second-line treatments primarily derives from four large pediatric clinical trials (TADS, TORDIA, ADAPT, and IMPACT). After two medications and a trial of evidence-based psychotherapy have failed to alleviate depressive symptoms, the evidence becomes quite thin for subsequent treatments. Here, we review the evidence for the effectiveness of medication switches, medication augmentation, psychotherapy augmentation, and interventional treatments (i.e., transcranial magnetic stimulation, electroconvulsive therapy, and ketamine) for adolescent TRD. Comparisons are drawn to the adult TRD literature, and areas for future pediatric depression research are highlighted.

CONCLUSIONS

As evidence is limited for treatments in this population, a careful consideration of the known risks and side effects of escalated treatments (e.g., mood stabilizers and atypical antipsychotics) is warranted and weighed against potential, but often untested, benefits.

PROTOCOL: A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents

This is the protocol for a Campbell review. The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regards to intervention completion/attrition (used as a proxy for intervention acceptability). The review will provide relative effect estimates and ranking probabilities for each outcome based on intervention delivery.

Racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders

OBJECTIVES

To compare the racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders (MDD).

METHODS

A retrospective cohort study was conducted using the 2005-2007 Medicaid claims data from Texas. Youth aged 10-20 during the study period were identified if they had two consecutive MDD diagnoses and received either medications for MDD or psychotherapy. Patients who received ≥84 days of medications and/or ≥4 sessions of psychotherapy for MDD treatment during 4 months of follow-up were considered meeting the minimum adequacy of treatment.

RESULTS

The generalized linear multilevel model (MLM) analysis revealed that both Hispanics and Blacks were approximately 30% less likely to receive adequate treatment (Hispanics - OR: 0.67; 95% CI: 0.6-0.8) (Blacks - OR: 0.66; 95% CI: 0.6-0.8) and Hispanic children were 50% more likely to undergo MH-related hospitalization (OR: 1.53; 95% CI: 1.1-2.2) compared to their White counterparts. The odds of meeting the minimum MDD treatment adequacy were comparable between pediatric MDD cases first identified by primary care providers (PCP-I) and psychiatrists (PSY-I) (PCP-I vs. PSY-I: OR: 0.97; 95% CI: 0.8-1.2), and slightly lower in those first identified by social workers/psychologists (SWP-I) as compared to PSY-I (SWP-I vs. PSY-I: OR: 0.81; 95% CI: 0.7-0.9). In all models, the interaction between race/ethnicity and type of provider who initiated MDD care was not statistically significant.

CONCLUSIONS

Minority youths received less adequate MDD treatment compared to Whites. Hispanic children had the highest risk of having mental health-related hospitalization. The specialty of provider who initiated MDD care had limited impact on treatment quality and was not associated with the racial/ethnic variations in treatment completion and mental health-related hospitalizations.

Adolescent Depression Curriculum Impact on Pediatric Residents' Knowledge and Confidence to Diagnose and Manage Depression

PURPOSE

Despite the need for pediatricians to diagnose and manage adolescent depression, few pediatric residency curricula exist. This study evaluated the impact of an adolescent depression curriculum on pediatric residents' knowledge and confidence to manage depression.

METHODS

A novel, case-based, adolescent depression curriculum simulating patient-provider continuity was developed and implemented within an adolescent medicine (AM) rotation. The curriculum addressed seven domains critical for diagnosis and management of adolescent depression. Participants were recruited from the pediatric residency at one institution. A survey assessed residents' demographics, prior training, and self-assessed knowledge and confidence within each domain using a retrospective pre-post evaluation. Wilcoxon signed-rank test evaluated changes in knowledge and confidence.

RESULTS

Forty-two of a total 51 residents (82%) completed the curriculum and survey during their AM rotation. Residents reported that within their continuity clinic, 45% (n = 19) had never initiated medication for depression, and 60% (n = 25) did not manage their adolescent patients' depression medications. Comparisons before and after participation in the curriculum, using the retrospective pre-post survey, demonstrated increased self-assessed knowledge (p < .001, for each domain) and confidence (p < .001, for each domain).

CONCLUSIONS

In this study, few residents reported experience initiating medication or managing adolescent depression in the continuity clinic. Residents demonstrated increased self-assessed knowledge and confidence to diagnose and manage adolescent depression after participation in a case-based adolescent depression curriculum simulating patient-provider continuity. Incorporation of training on management of adolescent depression into AM rotation may be a feasible option to standardize training within pediatric residency.

Self-harm behaviors, suicidal ideation, and associated factors among rural left-behind children in west China

PURPOSE

This population-based cross-sectional study describes self-harm (SH) behaviors and associated factors in 2898 Chinese left-behind children (LBC).

METHODS

Descriptive statistics were used to present and compare the distributional characteristics of SH behaviors. Binary and ordinal logistic-regression models for survey data were applied to explore associated factors of SH.

RESULTS

Among the LBC, 48% (95% CI: 42%-54%) reported SH behaviors. SH was prominently associated with suicidal ideation. Boys, junior high-school students, and LBC whose fathers were poorly educated were observed to have higher prevalence of SH. Boys, local ethnic minorities, junior high-school students, and LBC whose fathers were comparatively well educated were observed to be at increased risk of more medically serious SH behaviors.

CONCLUSIONS

SH is a substantial public health problem among rural Chinese LBC. Targeted intervention measures should be developed to reduce future suicide risk.

Youth StepCare: a pilot study of an online screening and recommendations service for depression and anxiety among youth patients in general practice

BACKGROUND

General Practitioners (GPs) are ideally placed to identify and manage emerging mental illness in young people, however, many report low levels of confidence in doing so. A web-based universal screening service delivered via a mobile tablet, Youth StepCare, was developed to assist GPs in identifying depression and anxiety symptoms in youth patients. This service also provided evidence-based treatment recommendations and fortnightly monitoring of symptoms. The current study assessed the feasibility and acceptability of delivering the Youth StepCare service in Australian general practices.

METHODS

A 12-week uncontrolled trial was undertaken between August 2018 and January 2019 in two general practices in NSW, Australia. The service was offered to all youth patients aged 14 to 17 years who visited a participating GP during the screening period with their parent or guardian. Youth patients reported the presence of depressive and anxiety symptoms using the self-report Patient Health Questionnaire-9 and the Generalised Anxiety Disorder Questionnaire-7. New cases were defined as those who reported symptoms but were not currently seeking help from their GP, nor had sought help in the past. Feasibility and acceptability among GPs and practice staff were assessed using a battery of questionnaires.

RESULTS

Five GPs and 6 practice staff took part. A total of 46 youth patients were approached, 28 consented, and 19 completed the screener (67.9%). Nine reported symptoms of anxiety or depression, two of which were new cases (22.2%). GPs and practice staff were satisfied with the service, reporting that there was a need for the service and that they would use it again.

CONCLUSIONS

The Youth StepCare service appears to be a useful tool for identifying youth with unidentified symptoms of mental illness that can be easily embedded into general practice. Further research would benefit from exploring the factors affecting initial GP uptake and a larger trial is required to determine the efficacy of the service on young people's symptom reduction.

Meta-Analysis: 13-Year Follow-up of Psychotherapy Effects on Youth Depression

OBJECTIVE

Youth depression is a debilitating condition that constitutes a major public health concern. A 2006 meta-analysis found modest benefits for psychotherapy versus control. Has 13 more years of research improved that picture? We sought to find out.

METHOD

We searched PubMed, PsychINFO, and Dissertation Abstracts International for 1960 to 2017, identifying 655 randomized, English-language psychotherapy trials for individuals aged 4 to 18 years. Of these, 55 assessed psychotherapy versus control for youth depression with outcome measures administered to both treatment and control conditions at post (κ = 53) and/or follow-up (κ = 32). Twelve study and outcome characteristics were extracted, and effect sizes were calculated for all psychotherapy versus control comparisons. Using a three-level random-effects model, we obtained an overall estimate of the psychotherapy versus control difference while accounting for the dependency among effect sizes. We then fitted a three-level mixed-effects model to identify moderators that might explain variation in effect size within and between studies.

RESULTS

The overall effect size (g) was 0.36 at posttreatment and 0.21 at follow-up (averaging 42 weeks after posttreatment). Three moderator effects were identified: effects were significantly larger for interpersonal therapy than for cognitive behavioral therapy, for youth self-reported outcomes than parent-reports, and for comparisons with inactive control conditions (eg, waitlist) than active controls (eg, usual care). Effects showed specificity, with significantly smaller effects for anxiety and externalizing behavior outcomes than for depression measures.

CONCLUSION

Youth depression psychotherapy effects are modest, with no significant change over the past 13 years. The findings highlight the need for treatment development and research to improve both immediate and longer-term benefits.

Psychosocial risk factors for suicidality in children and adolescents

Suicidality in childhood and adolescence is of increasing concern. The aim of this paper was to review the published literature identifying key psychosocial risk factors for suicidality in the paediatric population. A systematic two-step search was carried out following the PRISMA statement guidelines, using the terms 'suicidality, suicide, and self-harm' combined with terms 'infant, child, adolescent' according to the US National Library of Medicine and the National Institutes of Health classification of ages. Forty-four studies were included in the qualitative synthesis. The review identified three main factors that appear to increase the risk of suicidality: psychological factors (depression, anxiety, previous suicide attempt, drug and alcohol use, and other comorbid psychiatric disorders); stressful life events (family problems and peer conflicts); and personality traits (such as neuroticism and impulsivity). The evidence highlights the complexity of suicidality and points towards an interaction of factors contributing to suicidal behaviour. More information is needed to understand the complex relationship between risk factors for suicidality. Prospective studies with adequate sample sizes are needed to investigate these multiple variables of risk concurrently and over time.

Transcranial photobiomodulation with near-infrared light from childhood to elderliness: simulation of dosimetry

Significance: Major depressive disorder (MDD) affects over 40 million U.S. adults in their lifetime. Transcranial photobiomodulation (t-PBM) has been shown to be effective in treating MDD, but the current treatment dosage does not account for head and brain anatomical changes due to aging. Aim: We study effective t-PBM dosage and its variations across age groups using state-of-the-art Monte Carlo simulations and age-dependent brain atlases ranging between 5 and 85 years of age. Approach: Age-dependent brain models are derived from 18 MRI brain atlases. Two extracranial source positions, F3-F4 and Fp1-Fpz-Fp2 in the EEG 10-20 system, are simulated at five selected wavelengths and energy depositions at two MDD-relevant cortical regions-dorsolateral prefrontal cortex (dlPFC) and ventromedial prefrontal cortex (vmPFC)-are quantified. Results: An overall decrease of energy deposition was found with increasing age. A strong negative correlation between the thickness of extracerebral tissues (ECT) and energy deposition was observed, suggesting that increasing ECT thickness over age is primarily responsible for reduced energy delivery. The F3-F4 position appears to be more efficient in reaching dlPFC compared to treating vmPFC via the Fp1-Fpz-Fp2 position. Conclusions: Quantitative simulations revealed age-dependent light delivery across the lifespan of human brains, suggesting the need for personalized and age-adaptive t-PBM treatment planning.

Is Digital Treatment the Holy Grail? Literature Review on Computerized and Blended Treatment for Depressive Disorders in Youth

Computerized and blended treatments seem to be an attractive treatment for adolescents as an alternative to face-to-face treatment, but mental health professionals seem hesitant to use these treatment modalities. This review provides an overview of factors contributing to and withholding from using computerized or blended treatment in routine care. Three databases were searched with terms related to (1) adolescents, (2) depression, (3) computerized or blended, and (4) treatment. Of the 33 articles identified, 10 focused on unguided computerized treatments, six on guided, two on blended, two compared unguided, blended- and face-to-face treatment to no treatment, and eight studies on games. Further, two articles that were focused on an online monitoring tool and three on intervention characteristics or preferred modes of help-seeking. Evidence for effectiveness, adherence, drop-out, and forming therapeutic relations were suspected to be barriers, but are no reason to reject computerized or blended treatment. Improvement in mental health literacy and the possibility to tailor the intervention are facilitators. However, adolescents' intention to seek help, acceptability of computerized treatment, symptom severity, time spent by therapist, and other facilities are identified as barriers and they need to be taken into account when using computerized or blended interventions. Nevertheless, computerized and blended are promising treatments for depressed youth.

Factors associated with depressive symptoms and suicidal ideation and behaviours amongst sub-Saharan African adolescents aged 10-19 years: cross-sectional study

OBJECTIVE

This study aimed to determine the burden of depression, suicidal ideation and suicidal behaviour amongst adolescents at sites in six sub-Saharan African countries and examine associated risk and protective factors.

METHODS

Household-based cross-sectional study involving male and female adolescents ages 10-19 years. A total of 7,662 adolescents from eight sites in six countries participated in the survey. Three sites were urban: Dar es Salaam (Tanzania), Harar (Ethiopia) and Ibadan (Nigeria); five were rural: Dodoma (Tanzania), Iganga/Mayuge (Uganda), Kersa (Ethiopia), Ningo Prampram (Ghana) and Nouna (Burkina Faso). Log-binomials models were used to estimate relative risks and confidence intervals for factors associated with depression and suicidal behaviour. This was supplemented using log-Poisson models as needed.

RESULTS

The prevalence of suicidal behaviour over the last 12 months ranged between 1.2% and 12.4% in the eight sites. Depressive symptoms and suicidal ideation/behaviours were associated with older age, female sex, food insecurity, poor access to health care and substance use. Depression was strongly associated with increased risk of suicidal behaviour at two sites where the multivariate model converged: Harar, Ethiopia (RR = 3.5, 95% CI 1.8, 7.0, P < 0.05) and Ibadan, Nigeria (RR = 3.7, 95% CI 2.2, 6.3, P < 0.0001).

CONCLUSIONS

Depressive symptoms and suicidal behaviour are common amongst sub-Saharan African adolescents at these 8 sites. Most factors associated with depressive symptoms are modifiable and preventable. Routine screening for depressive symptoms in services frequented by adolescents in these and similar communities would be crucial in early detection and prompt intervention.

Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression

OBJECTIVE

Despite advances in evidence-based treatments for youth depression in recent decades, overall treatment effects are modest at best, with 30% to 50% of youth being nonresponders. Practice parameters consistently recommend systematic assessment and routine monitoring of depressive symptoms, or measurement-based care (MBC), to enhance youth depression treatment. However, the literature offers few guidelines on how to use assessment results to inform care decisions or to detect real and clinically meaningful change. Thus the current study produced reliable change indices (RCIs) per Jacobson and Truax for two commonly used standardized assessments of youth depression (ie, Patient Health Questionnaire-9 items, Modified for Adolescents [PHQ-9A], the Short Moods and Feelings Questionnaire [SMFQ]).

METHOD

The study sample (N = 1,738) consisted of youths 6 to 18 years old seen in a child and adolescent psychiatry clinic of a regional pediatric medical center who completed at least one of the target depression measures. We examined the factor structure and internal reliability for the PHQ-9A, and calculated RCIs for patients with a depression-related diagnosis for both measures.

RESULTS

Analyses confirmed a one-factor solution and adequate internal consistency (α = .86) for the PHQ-9A. All measures yielded acceptable test-retest reliabilities (r > 0.75) and RCIs that equate to clinical practice recommendations of using reliable changes scores of 7, 6, and 8 for the PHQ-9A, the SMFQ-Child Report, and the SMFQ-Parent Report, respectively.

CONCLUSION

Psychometric validation of the PHQ-9A and these RCIs are timely and significant contributions to the treatment of youth depression, by facilitating effective use of MBC-a critical evidence-based strategy for improving treatment outcomes.

Management of Depression in Adolescents in Japan

Objectives: In Japan, there are currently no approved antidepressant treatments for pediatric patients with depression. This study aimed to estimate the prevalence of depression among adolescents under medical care in Japan, the pharmacological treatments used, and the perceived unmet needs among the medical specialties treating depression in the pediatric population. Methods: The study was conducted in November 2014 as an internet survey among physicians in clinical practice. It included a sample of 731 physicians with the potential to treat adolescent patients with depression and 161 physicians who had treated at least one adolescent with depression with pharmacotherapy in the previous 12 months. Of the sample of 161 treating physicians, 60 were internal medicine specialists, 73 were psychiatrists, and 28 were certified specialists from the Japanese Society of Child and Adolescent Psychiatry, Japanese Society of Psychosomatic Medicine Pediatrics, or Japanese Society of Pediatric Psychiatry and Neurology. The participants completed questionnaires concerning their patient population with depression, drug-treated population, and drugs prescribed. Results: Estimates of prevalence data indicated that there were ∼550,000 adolescent patients with depression in Japan (10% of the patient population with depression) under medical care of different medical specialties; ∼64% of these patients were receiving pharmacotherapy. Pharmacotherapy for adolescents with depression was prescribed mainly by psychiatrists (62% of prescriptions for these patients). The most common first-choice agent was sertraline (23% of respondents) followed by anxiolytics (17%) and fluvoxamine (13%), while antipsychotics were the preferred choice for 7%. Conclusion: The study indicates a high prevalence of depression among adolescents in Japan. These patients are seen by different medical specialties; the use of pharmacotherapy is relatively common and comprises various drug classes, including antidepressants, anxiolytics, and antipsychotics. This study shows that there is a medical need for approved treatments for adolescents with depression in Japan.

Prescription Benzodiazepine Use in Privately Insured U.S. Children and Adolescents

INTRODUCTION

Benzodiazepines are commonly prescribed in the U.S. but entail safety concerns, including dependency. In pediatrics, many indications lack trial data. Authors aimed to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use.

METHODS

The study cohort included children (aged 3-12 years) and adolescents (aged 13-17 years) initiating prescription benzodiazepine treatment (≥3 days' supply) from January 2010 to September 2015 in a U.S. commercial claims database. Potential indications included selected ICD-9-CM diagnoses (≤30 days prior). Long-term (≥6 months) benzodiazepine treatment was estimated with Kaplan-Meier estimation and modified Poisson regression identified independent predictors of long-term benzodiazepine treatment (analysis completed in 2018).

RESULTS

Of 24,504 children and 61,046 adolescents initiating benzodiazepines, 62% of the children and 68% of the adolescents had a potential indication. Anxiety disorders were the most common indication, with mental health indications more common among adolescents (45%) than children (23%) and epilepsy and movement disorders higher in children. Recent opioid prescriptions were common before benzodiazepine initiation (children, 22%; adolescents, 21%). Six percent of the initiators became long-term benzodiazepine users. Potential indication, provider contact, psychotropic medication, and chronic conditions independently predicted long-term benzodiazepine treatment in adolescents and children.

CONCLUSIONS

U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. Long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.

Inpatient Psychiatric Care Outcomes for Adolescents: A Test of Clinical and Psychosocial Moderators

Financial pressures have led to a reduced length of stay (LOS) in inpatient psychiatric facilities for adolescents, yet research on the outcomes of short-term programs remains scant. The present study evaluated the outcomes of an adolescent inpatient program by: (1) probing depression, anxiety, and suicidal ideation at admission and discharge and (2) testing whether clinical or psychosocial factors moderate treatment response. Participants included adolescents (n = 777) aged 13-19 years admitted to an inpatient treatment program for acute psychiatric concerns. Clinical interviews were administered to probe mental disorders and past suicidal thoughts and behaviors (STBs), and self-report measures assessed symptom severity, child abuse, and peer victimization (i.e., bullying). Results showed a significant decrease in depression, anxiety, and suicidal ideation from admission to discharge. Comorbidity, past month NSSI, and lifetime suicide attempts emerged as moderators of treatment response, and peer victimization predicted symptom severity at discharge. Although findings suggest an overall improvement, participants with more severe clinical presentations (e.g., comorbidity, past month NSSI, lifetime suicide attempts, and more severe bullying) reported greater symptom severity at admission and discharge, suggesting that these patients may benefit from longer inpatient stays to achieve further symptom reduction. Although this may incur greater costs in the short-term, it also may prevent unintended economic and psychosocial consequences in the long-term.

Lifestyle, appearance satisfaction and depressive symptoms in 13-16 years old Norwegian adolescents - A cross-sectional study

Purpose: To examine gender-specific associations between multiple lifestyle-related risk factors, appearance satisfaction and depressive symptoms in a sample of Norwegian adolescents (13-16 years of age), and to study the role of appearance satisfaction as a possible confounder in the associations between lifestyle and depressive symptoms. Materials and methods: Data were obtained from Ungdata, a cross-sectional national survey of adolescents in Norway. In total 4379 subjects were included in the study. We constructed a lifestyle risk index and used multiple logistic regressions to examine the associations between lifestyle-related risk factors, appearance satisfaction, and depressive symptoms. Results: High screen time and use of alcohol were significantly associated with depressive symptoms among girls, while high screen time, tobacco and cannabis use were significantly associated with depressive symptoms among boys. An additive relationship was observed between the lifestyle risk index scores and the likelihood of depressive symptoms for both genders, the relationship being strongest among boys. Low appearance satisfaction was strongly associated with depressive symptoms, especially among boys, and identified as an important confounder in the associations between lifestyle and depressive symptoms, particularly among girls. Conclusions: High screen time was the most prevalent lifestyle risk behavior independently associated with depressive symptoms. Multiple lifestyle changes and improvement of appearance satisfaction should be included in measures targeting adolescents for the prevention and treatment of depressive symptoms. Future studies should elaborate on the gender differences in other adolescent age groups. Appearance satisfaction should be acknowledged as an important confounder in future studies of lifestyle and depressive symptoms.

Feasibility and clinical effects of theta burst stimulation in youth with major depressive disorders: An open-label trial

BACKGROUND

Conventional treatments for youth depression, such as antidepressants, have modest efficacy, side effects, and ongoing controversies regarding safety. Repetitive transcranial magnetic stimulation (rTMS), specifically theta burst stimulation (TBS), applied to the dorsolateral prefrontal cortex (DLPFC) has demonstrated efficacy for the treatment of depression in adults. However, the feasibility and clinical response to TBS for youth depression has yet to be explored.

METHODS

Twenty participants between the ages of 16 to 24 years old with MDD were recruited. The intervention consisted of 10 treatment sessions over the course of two weeks, in which participants received intermittent TBS and continuous TBS stimulation to the left and right DLPFC, respectively. Change in the Hamilton Rating Scale for Depression (HRSD-17) score was the primary outcome. Clinical assessments occurred at baseline, after the fifth treatment session, and within a week after treatment completion.

RESULTS

Of the twenty participants, eighteen received all TBS sessions, and seventeen completed all clinical assessments. There was a significant reduction in depressive symptoms following treatment completion (p < 0.001). Four of the twenty patients had more than 50% reduction in their depressive symptoms, two of whom achieved remission. All participants received and tolerated at least six daily TBS treatments with no major adverse events.

LIMITATIONS

Study was an uncontrolled, open-label design.

CONCLUSION

Ten sessions of TBS was feasible, well tolerated, and appeared to have clinical effects for the treatment of depressed youth. Future sham-controlled randomized trials are warranted to validate these findings in a larger cohort of youth depression.

Neurocognitive Predictors of Clinical Improvement in Selective Serotonin Reuptake Inhibitor-Treated Adolescents with Major Depressive Disorder

OBJECTIVES

Numerous studies have suggested cognitive deficits as consistently associated with adolescent depression. No study to date, however, has assessed neurocognitive predictors of selective serotonin reuptake inhibitor (SSRI) treatment response in adolescents with depression. This study examined neurocognitive tasks at baseline as predictors of clinical improvement with SSRI treatment (fluoxetine) at week 6 and 12 in an adolescent population.

METHODS

Adolescents with depression were recruited from a child and adolescent psychiatry outpatient clinic at a university medical center. Twenty-four adolescents (mean age 14.8 years) with Major Depressive Disorder completed tasks of the Cambridge Neuropsychological Test Automated Battery, including visual memory, executive functioning, sustained attention, and impulsivity. Depression severity, measured by the Children's Depression Rating Scale-Revised (CDRS-R), was assessed at week 6 and 12 and clinical improvement was defined as percentage (%) change in CDRS-R from baseline.

RESULTS

Clinical improvement is noted at both week 6 (mean % change in CDRS-R [M] = 46.8, standard deviation [SD] = 51.9) and week 12 (M = 87.9, SD = 57.2). Results reveal that less difficulty in sustained attention (p = 0.02), lower impulsivity (p = 0.00), and better planning (p = 0.04) at baseline were predictors of greater clinical improvement at week 6. Lower impulsivity at baseline remained significantly predictive of clinical improvement at week 12 (p = 0.01).

CONCLUSION

Neurocognitive assessments could potentially help identify a subset of depressed adolescents who may not respond to conventional SSRI treatment and who may be better candidates for alternative or augmentation treatments.

Effectiveness and Cost-Effectiveness of Blended Cognitive Behavioral Therapy in Clinically Depressed Adolescents: Protocol for a Pragmatic Quasi-Experimental Controlled Trial

Background

Cognitive behavioral therapy (CBT) is an effective intervention to treat depressive disorders in youth. However, 50% of adolescents still have depressive symptoms after treatment, and 57% drop out during treatment. Online CBT interventions have proven to be effective in reducing depressive symptoms and seem promising as a treatment for depressed adolescents. However, combining online programs with face-to-face sessions seems necessary to increase their effectiveness and monitor for suicide risk.

Objective

In this study, we examine the effectiveness and cost-effectiveness of a blended CBT treatment protocol, a mixture of online and face-to-face CBT, as a treatment for clinically depressed adolescents.

Methods

A pragmatic quasi-experimental controlled trial will be conducted to study the effectiveness of a blended CBT treatment protocol, in which blended CBT is compared with face-to-face CBT (n=44) and treatment as usual (n=44); the latter two were collected in a previous randomized controlled trial. The same inclusion and exclusion criteria will be used: adolescents aged between 12 and 21 years, with a clinical diagnosis of a depressive disorder, and referred to one of the participating mental health institutions. Assessments will be conducted at the same time points: before the start of the intervention, during the intervention (after 5 and 10 weeks), postintervention, and at 6- and 12-month follow-ups.

Results

The primary outcome is the presence of a depression diagnosis at 12-month follow-up. Several secondary outcomes will be measured, such as depressive symptoms, quality of life, and suicide risk. Costs and effects in both conditions will be compared to analyze cost-effectiveness. Further, moderating (age, gender, alcohol and drug use, parental depression, and other psychopathology) and mediating effects (negative automatic thoughts, cognitive emotion regulation, attributional style) will be analyzed. Also, treatment characteristics will be studied, such as characteristics of the therapists, treatment expectancy, and therapeutic alliance. Dropout rates and treatment characteristics will be measured to study the feasibility of blended CBT.

Conclusions

This study will examine the effectiveness and cost-effectiveness of a blended CBT program in which depressed adolescents are treated in mental health care. Results of blended CBT will be compared with face-to-face CBT and treatment as usual, and implications for implementation will be reviewed.

Trial Registration

Dutch Trial Register (NTR6759); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6759

International Registered Report Identifier (IRRID)

DERR1-10.2196/13434 RR1-10.2196/12654