Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive Disorders

Depression and Social Media Use in Children and Adolescents

Since the opening of Facebook to the general public in late 2006 social media use has rapidly become nearly universal among adolescents, providing new opportunities for connecting with peers, exploring identity, and expressing creativity. During the same period, rates of depression and suicide among youth have risen. A growing body of evidence highlights a correlation between problematic social media use and depression. Social media does not affect all children and adolescents equally.

Worsening sleep predicts next-week suicidal ideation in a high-risk adolescent outpatient treatment sample

INTRODUCTION

Suicidal thoughts and behaviors often onset during adolescence, constituting a major public health concern. Despite rising rates in youth, psychotherapeutic and pharmacological treatment outcomes remain meager, indicating a need to identify modifiable risk factors. Experts suggest sleep may serve as a promising clinical indicator of risk and treatment progress, yet few studies have examined acute temporal associations between sleep and suicidal ideation.

METHODS

Participants were depressed and suicidal adolescents (age 13-19, n = 311) attending an intensive outpatient program (IOP). Patients completed weekly self-report assessments of sleep, depression, and suicidal ideation throughout IOP, with an average of 5 assessments over 30 days.

RESULTS

Greater overall sleep difficulties, as well as within-person increases in sleep difficulties, were predictive of greater depression severity and suicidal ideation at subsequent assessments, above and beyond previous levels of symptoms. The reverse associations were not found. Inclusion of within-person changes in sleep difficulties significantly improved model fit compared to inclusion of overall sleep difficulties alone.

DISCUSSION

This study provides additional evidence for a prospective relationship between worsening sleep difficulties and suicidal ideation in an IOP youth sample. Worsening sleep may be an important clinical indicator of subsequent depression and suicide risk among adolescents in treatment.

Effects of electroconvulsive therapy on functional connectome abnormalities in adolescents with depression and suicidal ideation

OBJECTIVES

Major depressive disorder (MDD) in adolescents is associated with an increased risk of suicide, and electroconvulsive therapy (ECT) is an effective treatment for MDD and suicidal ideation. To investigate underlying central mechanisms, this study examined functional connectome topological organization in adolescents with MDD and suicidal ideation prior to and following ECT.

METHODS

Resting-state fMRI images were collected from 28 adolescents with MDD and suicidal ideation and 31 demographically similar healthy adolescents. Whole-brain functional networks were constructed and topological metrics were analyzed using graph theory approaches.

RESULTS

Prior to ECT, depressed adolescents showed disrupted global and nodal properties, indicating altered functional connectivity. Following ECT, significant reductions in depression and suicidality symptoms were observed, with a 75 % response rate. ECT led to an increase in the small-worldness of the brain network, suggesting restoration of functional connectivity. Significant improvements were seen in nodal properties, particularly in the central executive network. Group-by-time interactions revealed differences between responders and non-responders in nodal degree and efficiency.

LIMITATIONS

Larger sample sizes and extended followed-up periods following ECT treatment are needed to further investigate the neural basis of clinical changes.

CONCLUSION

The results of this study reveal dynamic changes in brain network topology of adolescents with depression during the course of ECT, and have an advanced understanding of the neurobiological biomarkers associated with the efficacy of ECT treatment.

Selective Serotonin Reuptake Inhibitor Prescribing Within an Integrated Pediatric Primary Care Behavioral Health Program

OBJECTIVE

Selective serotonin reuptake inhibitor (SSRI) prescribing is increasingly being integrated into primary care, but few data are available about prescribing patterns by pediatric primary care clinicians (PCCs) following implementation of integrated behavioral health (BH) care.

METHODS

Using administrative claims data, we performed a cross-sectional analysis of SSRI prescribing within a statewide pediatric primary care network over 10 years after the initiation of an integrated BH program, calculating the rate of PCC and specialist SSRI prescribing. Using electronic health record data, we analyzed a proposed set of quality metrics for SSRI initiation.

RESULTS

Over 10 years, SSRI prescribing by PCCs increased from 56 fills/1000 patient-years to 446; over the same time period, prescribing by specialists for the network's patients rose from 233 fills/1000 patient-years to 380. In 2013, PCCs prescribed 19% of all SSRIs, while by 2022, they prescribed 54% of the total (P < 0.001 for change for PCCs compared to specialists). Among 16,272 initial SSRI prescribing events by PCCs, 99.6% prescribed a recommended SSRI; 97.5% used an appropriate starting dose; 55.2% documented a validated symptom rating scale at initiation; 53.4% had a contact within 14 days; 67.8% had a follow-up visit within 60 days; and 37.4% documented a symptom rating scale within 60 days.

CONCLUSIONS

In the first 10 years of a pediatric integrated BH program, SSRI prescribing by PCCs increased over 7-fold and surpassed specialist prescribing for the patient population. PCCs chose medications and starting doses appropriately but could improve their use of validated symptom rating scales and consistent follow-up.

Enhancing Nursing Care through Cultural Competence: Focus on the Inupiat Community

INTRODUCTION

This article explores the historical and cultural background of the Inupiat community, highlighting health disparities and emphasizing culturally competent care's role in addressing them.

METHODS

Inupiat health beliefs, communication styles, family dynamics, and dietary habits are examined in relation to Western medical practices within tribal health systems. Strategies for cultural education include curriculum development, simulations, clinical assignments, and partnerships with Inupiat healthcare professionals.

RESULTS

Challenges in providing culturally competent care to the Inupiat community are identified, including barriers in nursing education and legal implications for nursing practice. Strategies for enhancing nursing cultural competency are outlined.

DISCUSSION

This paper advocates integrating cultural competency into nursing practices to improve care for the Inupiat community, focusing on training, education, and policy recommendations. It emphasizes the importance of respecting and integrating Inupiat cultural practices to enhance health outcomes and healthcare experiences.

Efficacy of unified protocol for transdiagnostic treatment of emotional disorders in adolescents (UP-A) in China: protocol for a randomised controlled trial

INTRODUCTION

Emotional disorders are highly prevalent among adolescents, with a high rate of comorbidity. Convenient and effective treatment options are needed to reduce costs and improve effectiveness. The unified protocol for transdiagnostic treatment of emotional disorders in adolescents (UP-A) is an evidence-based transdiagnostic approach aimed at ameliorate emotional symptoms. The objective of this study is to assess the efficacy of the UP-A in Chinese adolescents with emotional disorders using multidimensional evaluations.

METHODS AND ANALYSIS

This study is a two-armed, randomised controlled trial on the efficacy of 12 week UP-A on adolescents with emotional disorders along with their parents. Forty-eight participants will be randomly assigned to either the treatment as usual (TAU) group or the TAU combined with UP-A (UP-A+TAU) group. We will evaluate the efficacy of the UP-A, through the following primary and secondary outcomes: emotional disorder severity, emotional symptoms, emotion regulation, cognitive patterns, executive function, resilience, quality of life, social and family functioning. Participants will be assessed at baseline (T1), week 4 (T2), week 8 (T3), post-treatment (T4) and 3 month follow-up (T5).

DISCUSSION

This protocol outlines the first randomised controlled trial investigating the efficacy of the UP-A among Chinese adolescents with emotional disorders. The findings may contribute to providing an effective and feasible transdiagnostic intervention in Chinese clinical settings.

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics and Clinical Research Committees of Peking University Sixth Hospital and will be performed under the Declaration of Helsinki with the Medical Research Involving Human Subjects Act (WMO). The results will be disseminated in a peer-reviewed journal and a conference presentation.

TRIAL REGISTRATION NUMBER

ChiCTR2300069354.

Contributing Factors to the Rise in Adolescent Anxiety and Associated Mental Health Disorders: A Narrative Review of Current Literature

BACKGROUND

The prevalence of anxiety among adolescents has seen a notable increase in recent years, becoming a significant public health concern. In fact, anxiety is substantially more prevalent in Generation Z (individuals born between 1997 and 2012) than in any of the past three generations. We aimed to examine what factors contribute to the increased prevalence in teen anxiety and identify points of intervention.

METHODS

This study employed a narrative review method. We performed a literature search of the PubMed, ScienceDirect, and Medline databases and identified original research and review articles discussing increased anxiety and other mental health disorders in Generation Z.

RESULTS

We provide a comprehensive overview of the factors contributing to the increased rates of adolescent anxiety, including academic pressures, social media influence, family dynamics, and broader societal stressors.

CONCLUSIONS

In this narrative review, we examine the multifaceted nature of adolescent anxiety, identifying contributing factors. Additionally, we discuss potential clinical, educational, and community-based interventions to prevent and treat adolescent anxiety. By understanding and addressing the underlying causes of anxiety, it is possible to mitigate its impact and promote healthier developmental trajectories for young individuals.

Trends in research on novel antidepressant treatments

Mood disorders, such as major depressive disorder and bipolar disorder, are among the most common mental illnesses and a leading cause of disability worldwide. Key symptoms of these conditions include a depressed mood or anhedonia, sleep and psychomotor disturbances, changes in appetite or weight, and fatigue or loss of energy. Prolonged cognitive disturbances further impair the ability to think or concentrate and are often accompanied by persistent feelings of worthlessness or excessive guilt. Collectively, these symptoms underscore depression as a serious, long-term global health issue. In addition, clinical studies indicate a growing number of patients experiencing difficulties in responding to treatment, even in the long term. This phenomenon poses significant challenges for healthcare professionals, families, and patients alike. As a result, there is an urgent need for therapies that are both rapid-acting and safe. This review aims to summarize the prevailing trends in research on novel antidepressants, emphasizing their diversity and multi-directional mechanisms of action. The development of rapid-acting drugs is increasingly focused on achieving high efficacy, particularly for treatment-resistant depression. Such advances offer the potential for rapid therapeutic effects without the prolonged and often tedious administration of older generation antidepressants. Findings from studies using animal models of depression continue to play a crucial role in predicting and designing new therapeutic strategies. These models remain indispensable for understanding the physiological effects of newly developed compounds, thereby guiding the creation of innovative treatments.

Negative efficacy of antidepressants in pharmacotherapy of child and adolescent depression

Antidepressants are the main drugs used to treat depression, but they have not been shown to be effective in the treatment of child and adolescent depression. However, many adolescent depression treatment guidelines still recommend the use of antidepressants, especially specific serotonin re-uptake inhibitors. Previous studies have suggested that antidepressants have little therapeutic effect but many side effects, such as switching to mania, suicide, and non-suicidal self injury (NSSI), in the treatment of child and adolescent depression. In the process of developing guidelines, drug recommendations should not only focus on improving symptoms, but they should also consider potential side effects. This review discusses the serious side effects of antidepressants, including switching to mania, suicide, and NSSI.

Systematic Review and Meta-Analysis: The Association Between Newer-Generation Antidepressants and Insomnia in Children and Adolescents With Major Depressive Disorder

OBJECTIVE

To examine the association between newer generation antidepressants and insomnia as an adverse event (AE) in the treatment of children and adolescents with major depressive disorder (MDD).

METHOD

A systematic search was performed in major databases (inception to August 31, 2023) to retrieve double-blind, placebo-controlled, randomized controlled trials (RCTs) evaluating the safety of 19 antidepressants in the acute treatment (initial 6-12 weeks) of children and adolescents ≤18 years of age with MDD (primary analyses). RCTs in anxiety disorders and obsessive-compulsive disorder (OCD) were retrieved from a recent meta-analysis and included in complementary analyses. A mixed-effects logistic regression model was used to compare the frequency of insomnia in the antidepressant relative to the placebo group. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool.

RESULTS

In total, 20 trials in MDD (N = 5,357) and 8 trials in anxiety disorders and OCD (N = 1,271) evaluating selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) were included. In MDD, antidepressant treatment was associated with a modest increase in the odds of insomnia compared with placebo (odds ratio [OR] = 1.65, 95% CI = 1.21-2.27, p = .002), with no significant difference between SSRIs and SNRIs. The RCTs showed low risk of bias or minor concerns for the assessment of insomnia. The odds of treatment-emergent insomnia were significantly lower in MDD (OR = 1.62; 95% CI = 1.21-2.15) compared to anxiety disorders and OCD (OR = 2.89; 95% CI = 1.83-4.57) for treatment with SSRIs (p = .03). Among individual antidepressants with evidence from ≥3 studies, sertraline had the highest OR (3.45; 95% CI = 1.91-6.24), whereas duloxetine had the lowest OR (1.38; 95% CI = 0.79-2.43).

CONCLUSION

Children and adolescents are at a modestly increased risk for experiencing insomnia during the first 6 to 12 weeks of treatment with SSRIs and SNRIs. Antidepressant- and disorder-specific variability in the risk of treatment-emergent insomnia may be relevant to consider in clinical decision making.

STUDY PREREGISTRATION INFORMATION

The association between newer generation antidepressants and insomnia in children and adolescents with major depressive disorder: a meta-analysis of randomized controlled trials; https://www.crd.york.ac.uk; CRD42023330506.

Current Utilization of Bupropion Treatment in Children, Young Adults, and Adults in the United States

Introduction: While available for decades, the use of bupropion has increased in recent years. To provide an updated review on the use of bupropion, this article aimed to describe bupropion prescription details, potential indication, and treatment duration in children, young adults, and adults starting bupropion treatment. Methods: Individuals aged 6-64 newly initiating bupropion hydrochloride treatment were identified from commercial claims data (MarketScan, 1/1/2016-12/31/2022). New bupropion use was defined as at least 1 year without any prior bupropion dispensed prescription. Potential indications for bupropion treatment were identified from inpatient/outpatient records (ICD-10-CM diagnoses) in the 30 days prior to bupropion initiation. All analyses were stratified by age: children (6-17 years), young adults (18-29 years), and adults (30-64 years) and treatment duration up to 1 year was estimated with Kaplan-Meier estimation. Results: The study sample included 39,833 children, 177,710 young adults, and 548,557 adults newly initiating bupropion treatment. Bupropion extended-release 24-hour 150 mg was the most common (62%) formulation and dose at initiation. Depression was the most prevalent potential indication (children = 57%, young adults = 47%, adults = 36%) and attention-deficit/hyperactivity disorder (ADHD) was the next most common potential indication in children (25%) and young adults (12%); tobacco cessation and weight loss also identified as potential indications. Twenty-two percent of bupropion initiators were on concurrent selective serotonin reuptake inhibitor treatment. In children, suicidal ideation (16.3%), poisoning (5.9%), and anorexia or bulimia nervosa (2.2%) were relatively common diagnoses prior to bupropion initiation. Overall, 39%-45% remained on bupropion treatment for at least 6 months, with variation by potential indication. Conclusion: The antidepressant bupropion is prescribed to children, young adults, and adults for a variety of indications in the United States, with depression and ADHD the most common indications in children. As the prescribing of bupropion becomes more widespread, additional safety and effectiveness data will be necessary to inform prescribing decisions, particularly in populations with unknown efficacy.

Anxiety, Depressive, and Eating Disorders in Adolescents

Adolescent anxiety, depressive, and eating disorders are a worsening population health issue that primary care clinicians play a critical role in addressing. Implementing universal screening into clinical practices for depression at age 12 years and anxiety at age 8 years is the first step to diagnosis. Referencing 5th edition of the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria is essential to making the correct diagnosis after ruling out underlying medical conditions. The evidence-based mainstays of treatment are unique to each specific disorder.

Racial and ethnic disparities in unmet need for mental health care among children: A nationally representative study

BACKGROUND

There is a dearth of large, nationally representative studies that examine racial/ethnic disparities in self-reported unmet need for mental health care among children and youth.

OBJECTIVE

This study assessed racial/ethnic disparities in unmet need for mental health care, use of psychotropic medication, and reasons for forgone care among children and youth.

METHODS

This nationally representative cross-sectional study analyzed data from the combined 2016-2020 National Survey of Children's Health (n = 151,876). Bivariate statistics and multivariable logistic regression models assessed the association between race/ethnicity, unmet need for mental health care, and use of psychotropic medication. Reasons for forgone care were also examined.

RESULTS

Black non-Hispanic children and youth had approximately twice the odds of unmet mental health care needs (AOR, 1.97; 95% CI 1.53-2.55) as White non-Hispanic children and youth. The likelihood of reporting that it was not possible to see a mental health professional was higher for Black non-Hispanic (AOR, 3.39; 95% CI 1.64-7.01) and Multi-racial/Other non-Hispanic children and youth (AOR, 2.96; 95% CI 1.40-6.25) compared with White non-Hispanic peers. Black non-Hispanic, Hispanic, and Multi-racial/Other non-Hispanic children and youth were also less likely to use psychotropic medication (p < 0.001). Common reasons for forgoing care included cost, problems getting an appointment, and lack of transportation or childcare.

CONCLUSIONS

This study found significant racial/ethnic disparities in unmet mental health care, psychotropic medication use, and barriers in accessing mental health care. Data from this study suggest that eliminating these disparities requires policy interventions that address medical and societal barriers to health care access and quality.

Service coverage for major depressive disorder: estimated rates of minimally adequate treatment for 204 countries and territories in 2021

BACKGROUND

Access to effective treatment for major depressive disorder remains limited and difficult to track across place and time. We analysed the available data on minimally adequate treatment (MAT) for major depressive disorder globally with the aim of providing a useful metric against which to monitor national responses to the growing public health burden imposed by major depressive disorder.

METHODS

MAT was defined as pharmacotherapy (1 month of medication, plus four visits to a medical doctor) or psychotherapy (eight visits with any professional). From existing reviews, we identified mental health surveys that assessed major depressive disorder within the general population as well as health service uptake by individuals with major depressive disorder. Data by ethnicity were not available. Estimates of MAT, antidepressant use, or use of any mental health service were extracted. The latter two estimates were adjusted to reflect likely MAT rates via a network meta-analysis. Adjusted MAT estimates were analysed via a Bayesian meta-regression using the Disease Modelling Meta-Regression (DisMod-MR 2.1) tool. This analysis estimated MAT coverage among people with major depressive disorder by age, sex, location, and year. Final MAT estimates were standardised by age and sex against the existing age and sex distribution of people with major depressive disorder globally. People with lived experience were involved in the design, preparation, interpretation, and writing of this manuscript.

FINDINGS

The analysed dataset included 145 estimates from 32 studies, covering 31 countries, 14 regions, and six super-regions. The proportion of people with major depressive disorder receiving MAT globally in 2021 was 9·1% (95% uncertainty interval 7·2-11·6), with 10·2% (8·2-13·1) of females and 7·2% (5·7-9·3) of males with major depressive disorder receiving MAT. MAT coverage was highest in high-income locations (27·0% [21·7-34·4]), with Australasia having the highest rate (29·2% [21·4-40·8]). MAT coverage was lowest in sub-Saharan Africa (2·0% [1·5-2·6]), within which western sub-Saharan Africa (1·8% [1·4-2·5]) had the lowest coverage. Seven countries (Australia, Belgium, Canada, Germany, the Netherlands, South Korea, and Sweden) were estimated to have MAT coverage exceeding 30%, while 90 countries were estimated to have coverage lower than 5%.

INTERPRETATION

Despite many gaps in the available data, estimates show that, globally, most individuals with major depressive disorder do not receive MAT. Services must improve to reach a global coverage that better meets the mental health needs of those with major depressive disorder. Urgent attention should be given to the scale-up of effective intervention strategies, especially in low-income and middle-income countries, as well as further research into better quality treatment options for major depressive disorder. We present a means by which the MAT gap for major depressive disorder can be quantified, to monitor and inform action by governments and international partners.

FUNDING

Queensland Health and the Bill & Melinda Gates Foundation.

Unraveling the complexities of adolescent depression: A call for action

The adolescent years are a period of profound change, both physically and psychologically. For many, these years are marked by excitement and exploration, but for others, they are fraught with challenges that can lead to significant mental health issues. Depression, in particular, has become an increasingly prevalent concern among adolescents worldwide, and its multifaceted etiology requires a comprehensive approach to understanding and intervention. A recent study on the relationships among negative life events, dysfunctional attitudes, social support, and depressive symptoms in Chinese adolescents offers valuable insights into the complex interplay between various factors contributing to adolescent depression. The authors explore a moderated mediation model to better understand how these factors interact with and contribute to the onset of depression. This article aims to delve into the key findings of the study, highlight its implications for clinical practice, and encourage further research in this critical area.

Dosing of antidepressants in relation to body weight in children and adolescents with overweight

Overweight and obesity in children and adolescents may impact pharmacokinetics and drug exposure. The aim of the present study was to evaluate doses of antidepressants in relation to body weight in children. We used data from the BMI Epidemiology Study (BEST) Gothenburg cohort and the National Prescribed Drug Register and included children and adolescents with a prescription of fluoxetine (n = 347) or sertraline (n = 733) and a weight measurement. For fluoxetine, individuals with overweight or obesity received slightly lower doses at first prescriptions, but not in iterated prescriptions. The weight-normalized dose was lower in individuals with overweight or obesity in first and iterated prescriptions, compared with normal weight (p < 0.01). For sertraline, there were no significant dose differences between individuals with overweight or obesity, compared with normal weight. However, pronounced differences were seen in dose per kilogram body weight in both first and iterated prescriptions (p < 0.01). We conclude that the doses of fluoxetine and sertraline were essentially similar in individuals with overweight or obesity, but the weight-normalized doses were clearly lower. Given the ongoing obesity epidemic, larger studies addressing optimal dosing in individuals with elevated weight are warranted.

Disparities in Access to Mental Health Services Among Children Diagnosed with Anxiety and Depression in the United States

Child and adolescent mental health are major public health concerns in the US. Overall, 20% of US children have a reported mental health condition, while an estimated 40% will be diagnosed with one by age 18. Despite these concerns, little is known about factors associated with access to mental health services among children and adolescents. We analyzed data from a sample of 6655 children (aged 6 to 17 years) with either anxiety and/or depression drawn from the 2020-2021 National Survey of Children's Health (NSCH). A multivariable logistic regression model was fit to investigate predisposing, enabling, and need factors associated with caregiver's (i.e., parent or other guardian) perceived access to mental health services for their children. Approximately 50.8% of caregivers perceived obtaining mental health services for their children to be somewhat difficult, very difficult, or impossible. Children meeting criteria for having a medical home had lower odds of experiencing such difficulties (adjusted [a]OR = 0.38; 95% CI: 0.30-0.49). Further, compared to children who sometimes or never had health insurance coverage for mental or behavioral health needs, children who were always insured (aOR: 0.19; 95% CI 0.14, 0.25) and those who usually had coverage (aOR: 0.38; 95% CI 0.28, 0.51) had lower odds of experiencing perceived difficulties in obtaining care. The results indicate several enabling and need predictors of perceived access to mental health services--highlighting potential structural barriers to care access. Efforts to address access challenges should adopt a multifaceted approach and be tailored to families living in poverty, those with limited health coverage, and minoritized children with less than optimal general health.

Consensus-based recommendations for the diagnosis and treatment of anxiety and depression in children and adolescents with epilepsy: A report from the Psychiatric Pediatric Issues Task Force of the International League Against Epilepsy

The Psychiatric Pediatric Issues Task Force of the International League Against Epilepsy (ILAE) aimed to develop recommendations for the diagnosis and treatment of anxiety and depression in children and adolescents with epilepsy. The Task Force conducted a systematic review and identified two studies that assessed the accuracy of four screening measures for depression and anxiety symptoms compared with a psychiatric interview. Nine studies met the eligibility criteria for treatment of anxiety and depressive disorders or symptoms. The risk of bias and certainty of evidence were assessed. The evidence generated by this review followed by consensus where evidence was missing generated 47 recommendations. Those with a high level of agreement (≥80%) are summarized. Diagnosis: (1) Universal screening for anxiety and depression is recommended. Closer surveillance is recommended for children after 12 years, at higher risk (e.g., suicide-related behavior), with subthreshold symptoms, and experiencing seizure worsening or therapeutic modifications. (2) Multiple sources of ascertainment and a formal screening are recommended. Clinical interviews are recommended whenever possible. The healthcare provider must always explain that symptom recognition is essential to optimize treatment outcomes and reduce morbidity. (3) Questioning about the relationship between symptoms of anxiety or depression with seizure worsening/control and behavioral adverse effects of antiseizure medications is recommended. Treatment: (1) An individualized treatment plan is recommended. (2) For mild depression, active monitoring must be considered. (3) Referral to a mental health care provider must be considered for moderate to severe depression and anxiety. (4) Clinical care pathways must be developed. (5) Psychosocial interventions must be tailored and age-appropriate. (6) Healthcare providers must monitor children with epilepsy who are prescribed antidepressants, considering symptoms and functioning that may not improve simultaneously. (7) Caregiver education is essential to ensure treatment adherence. (8) A shared-care model involving all healthcare providers is recommended for children and adolescents with epilepsy and mental health disorders. We identified clinical decisions in the management of depression and anxiety that lack solid evidence and provide consensus-based guidance to address the care of children and adolescents with epilepsy.

The relationship between anxiety and diet quality in adolescent populations: a cross-sectional analysis

Globally, more than 13 % of adolescents have clinically significant mental health problems, with anxiety and depression comprising over 40 % of cases. Despite the high prevalence of anxiety disorders among youth, dietary research has been focused on youth with depression, resulting in a significant knowledge gap regarding the impact of anxiety on adolescent diet quality. Adolescents with diagnosed anxiety disorders and healthy controls were included in this study. Anxiety symptoms were measured using the Screen for Child Anxiety-Related Disorders. Diagnosis of anxiety disorder was determined using the Kiddie Schedule for Affective Disorders and Schizophrenia interview. Five diet quality indices were scored from FFQ. Diet quality indices associated with anxiety symptoms in the correlation matrix were interrogated using multiple linear regression modelling. All models were adjusted for depression. One hundred and twenty-eight adolescents (mean age 14·8 years (sd: 2·1); 66·4 % female) were included in this cross-sectional analysis. Although healthy controls and outpatient participants had similar unhealthy dietary index subscale scores, outpatient participants had lower healthy index scores. Higher anxiety symptoms were associated with lower healthy dietary indices in univariate analysis; after adjusting for comorbid depression; however, anxiety symptoms were no longer associated with dietary indices following adjustment for multiple testing (P = 0·038 to P = 0·077). The association between anxiety symptoms and a poor diet is attenuated by depression. The results of this study support the need for an integrated approach to the assessment of mental and physical well-being and further research aimed at understanding the unique contribution of depression to healthy dietary patterns.

Discriminative validity and interpretability of the mood and feelings questionnaire

BACKGROUND

Using the Mood and Feelings Questionnaire (MFQ) to differentiate between depression severity levels remains unexplored. We explored the discriminative validity of the MFQ to identify an optimal cut-off MFQ score to distinguish between subthreshold-to-mild and moderate-to-severe depression severity levels.

METHODS

An observational cross-sectional design was used in a sample (N = 67) of help-seeking youth (ages 13 to 18, inclusive) experiencing depressive symptoms. The MFQ was administered verbatim to youth by a research analyst over the phone. Youth were then grouped into subthreshold-to-mild or moderate-to-severe depression severity categories based on scores received on the Kiddie Schedule for Affective Disorders and Schizophrenia-Depression Rating Scale. Receiver Operating Characteristic curve analyses were conducted, with area under the curve (AUC) and Youden Index (J) as primary indices. We hypothesized that the lower limit of the 95 % confidence interval for the area under the curve would be ≥0.70.

RESULTS

The primary analysis yielded an AUC of 0.85 (95 % CI: 0.763-0.947) and an optimal cut-off of ≥43 (J = 0.60, positive predictive value = 91.4 %, negative predictive value = 62.5 %, sensitivity = 72.7 %, specificity = 87.0 %).

LIMITATIONS

Our study collected a small sample, and as such cannot identify how subgroup classification (e.g., based on race or gender) may moderate outcomes. Further, unknown measurement error of the predictor and reference variable measures can bias the estimates.

CONCLUSIONS

Our preliminary findings highlight the potential for the MFQ to support clinical decision-making relevant to adolescents experiencing varying severities of depressive symptoms in secondary care settings.

Predictive factors for the development of depression in children and adolescents: a clinical study

Background

The prevalence of depression among adolescents has been gradually increasing with the COVID-19 pandemic, and the purpose of this study was to develop and validate logistic regression models to predict the likelihood of depression among 6-17 year olds.

Methods

We screened participants from the National Center for Health Statistics (NCHS) in 2022. Independent risk factors were identified via univariate logistic regression analyses and least absolute shrinkage and selection operator (LASSO) for feature screening. Area under the curve (AUC) and decision curve analysis (DCA) were used to compare the predictive performance and clinical utility of these models. In addition, calibration curves were used to assess calibration.

Results

Multivariate logistic regression analyses revealed that risk factors for depression included girls, higher age, treated/judged based on race/ethnicity, ever lived with anyone mentally ill, experienced as a victim of/witnessed violence, and ever had autism, ever had attention-deficit disorder (ADD), etc. Afterwards, the results are visualized using a nomogram. The AUC of the training set is 0.731 and the AUC of the test set is 0.740. Also, the DCA and calibration curves demonstrate excellent performance.

Conclusion

Validated nomogram can accurately predict the risk of depression in children and adolescents, providing clues for clinical practitioners to develop targeted interventions and support.

Depression and Anxiety Among US Children and Young Adults

Importance

Data from surveys show increased mental health disorders in youths. However, little is known about clinical diagnosis over time.

Objective

To assess the incidence, prevalence, and changes from 2017 to 2021 for depression and anxiety diagnosed clinically among children, adolescents, and young adults and to identify potential disparities.

Design, Setting, and Participants

This cohort study included approximately 1.7 million individuals aged 5 to 22 years in Southern California. Data were extracted from electronic medical records; International Statistical Classification of Diseases, Tenth Revision (ICD-10), codes were used to identify depression and/or anxiety diagnosis for each study year from January 1, 2017, to December 31, 2021. Rates were stratified by age, gender, race and ethnicity, estimated household income, weight status, and comorbidity history. Changes over time and association with these variables were assessed using Poisson regression. Data were analyzed between June 1, 2022, and November 29, 2023.

Main Outcomes and Measures

Clinical diagnosis of (1) depression and (2) anxiety without a depression diagnosis using ICD-10 codes.

Results

Among the 1.7 million participants, mean (SD) age was approximately 14 (5) years, and 51% were male. In terms of race and ethnicity for each study year, approximately 50% of participants were Hispanic; 8%, non-Hispanic Asian; 8%, non-Hispanic Black; and 23%, non-Hispanic White. From 2017 to 2021, depression diagnosis increased by 55.6% (from 1.35% to 2.10%) for incidence and 60.0% (from 2.55% to 4.08%) for prevalence; anxiety without depression diagnosis increased by 31.1% (from 1.77% to 2.32%) for incidence and 35.2% (from 3.13% to 4.22%) for prevalence (P < .001 for trend). The increases in rates were higher during the COVID-19 pandemic (2020-2021) than before the pandemic (2017-2019), except for depression incidence. Rates increased across all subgroups. Rates were highest for subgroups aged 14 to 17 and 18 to 22 years; female participants; those of non-Hispanic American Indian or Alaska Native, non-Hispanic White, or multiple races or ethnicities; and subgroups with higher household income, obesity (and underweight for anxiety without depression), or comorbidities. Among these factors, age was the most important factor for depression diagnosis, whereas weight status was the most important factor for anxiety without depression diagnosis.

Conclusions and Relevance

This cohort study, using electronic medical record data from a large integrated health care system, found an increase in clinically diagnosed depression from 2017 to 2021, with a higher increase during the COVID-19 pandemic and higher rates in some subgroups. Equally important, this study identified high rates and an increase in clinical diagnosis of anxiety without a depression diagnosis. These results support the increased need in public health and health care effort to combat the mental health crisis in youths.

Longitudinal development of resting-state functional connectivity in adolescents with and without internalizing disorders

Longitudinal studies using resting-state functional magnetic resonance imaging (rs-fMRI) focused on adolescent internalizing psychopathology are scarce and have mostly investigated standardized treatment effects on functional connectivity (FC) of the full amygdala. The role of amygdala subregions and large resting-state networks had yet to be elucidated, and treatment is in practice often personalized. Here, longitudinal FC development of amygdala subregions and whole-brain networks are investigated in a clinically representative sample. Treatment-naïve adolescents with clinical depression and comorbid anxiety who started care-as-usual (n = 23; INT) and healthy controls (n = 24; HC) participated in rs-fMRI scans and questionnaires at baseline (before treatment) and after three months. Changes between and within groups over time in FC of the laterobasal amygdala (LBA), centromedial amygdala (CMA) and whole-brain networks derived from independent component analysis (ICA) were investigated. Groups differed significantly in FC development of the right LBA to the postcentral gyrus and the left LBA to the frontal pole. Within INT, FC to the frontal pole and postcentral gyrus changed over time while changes in FC of the right LBA were also linked to symptom change. No significant interactions were observed when considering FC from CMA bilateral seeds or within ICA-derived networks. Results in this cohort suggest divergent longitudinal development of FC from bilateral LBA subregions in adolescents with internalizing disorders compared to healthy peers, possibly reflecting nonspecific treatment effects. Moreover, associations were found with symptom change. These results highlight the importance of differentiation of amygdala subregions in neuroimaging research in adolescents.

Multilevel barriers to guideline implementation: a nationwide multi-professional cross-sectional study within child and adolescent psychiatry

BACKGROUND

Despite efforts to promote guideline use, guideline adoption is often suboptimal due to failure to identify and address relevant barriers. Barriers vary not only between guidelines but also between settings, intended users, and targeted patients. Multi-professional guidelines are often used in child and adolescent mental health services (CAMHS), making the implementation process more difficult. Despite this, there is a lack of knowledge about which barriers to consider or if barriers vary by profession. The aim of this study was to address these gaps by examining barriers to adopting a multi-professional depression guideline in the context of a nationwide implementation study.

METHODS

440 CAMHS clinicians across Sweden (52%) completed the Barriers and Facilitators Assessment Instrument (BFAI) ahead of an implementation endeavour. BFAI is a widely used and validated measure of guideline implementation on four scales: Innovation, Provider, Context, and Patient. Barriers were calculated at scale and at item levels. ANOVA and chi-square tests were used to analyse differences by profession and effect sizes were calculated.

RESULTS

Overall, clinicians were optimistic about guideline uptake, particularly about guideline characteristics and their own adoption ability. Barriers were related to the patient and the context domains, as well as to individual clinician knowledge and training. Perceptions differed across professions; psychiatrists were most, and counsellors were least positive about guideline embeddedness.

CONCLUSION

This large-scale quantitative study suggests that CAMHS clinicians have an overall favourable attitude towards guideline adoption but highlights the need for adaptations to certain patient groups. Strategies to improve guideline use should primarily address these patient issues while securing proper support to the implementation. Implementation efforts, particularly those targeting staff knowledge, training, and involvement, may benefit from being tailored to different professional needs. These findings may inform implementation projects in CAMHS and future research.

A Dose-Finding, Biomarker Validation, and Effectiveness Study of Transcranial Magnetic Stimulation for Adolescents With Depression

OBJECTIVE

Research and clinical application of transcranial magnetic stimulation (TMS) for adolescents with major depressive disorder has advanced slowly. Significant gaps persist in the understanding of optimized, age-specific protocols and dosing strategies. This study aimed to compare the clinical effects of 1-Hz vs 10-Hz TMS regimens and examine a biomarker-informed treatment approach with glutamatergic intracortical facilitation (ICF).

METHOD

Participants with moderate-to-severe symptoms of major depressive disorder were randomized to 30 sessions of left prefrontal 1-Hz or 10-Hz TMS, stratified by baseline ICF measures. The primary clinical outcome measure was the Children's Depression Rating Scale-Revised (CDRS-R). The CDRS-R score and ICF biomarker were collected weekly.

RESULTS

A total of 41 participants received either 1-Hz (n = 22) or 10-Hz (n = 19) TMS treatments. CDRS-R scores improved compared with baseline in both 1-Hz and 10-Hz groups. For participants with low ICF at baseline, the overall least squares means of CDRS-R scores over the 6-week trial showed that depressive symptom severity was lower for participants treated with 1-Hz TMS than for participants who received 10-Hz TMS. There were no significant changes in weekly ICF measurements across 6 weeks of TMS treatment.

CONCLUSION

Low ICF may reflect optimal glutamatergic N-methyl-d-aspartate receptor activity that facilitates the therapeutic effect of 1-Hz TMS through long-term depression-like mechanisms on synaptic plasticity. The stability of ICF suggests that it is a tonic, traitlike measure of N-methyl-d-aspartate receptor-mediated neurotransmission, with potential utility to inform parameter selection for therapeutic TMS in adolescents with major depressive disorder.

CLINICAL TRIAL REGISTRATION INFORMATION

Biomarkers in Repetitive Transcranial Magnetic Stimulation (rTMS) for Adolescent Depression; https://clinicaltrials.gov; NCT03363919.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list.

Depression Part 2: Treatment

Depression treatment strategies are within the scope of pediatric practice and among the competencies recommended by the Academy of Pediatrics and The American Board of Pediatrics. Treatments that may be provided through collaborative care include nonpharmacologic therapies such as psychosocial treatments and evidence-based psychotherapies, and pharmacotherapy and monitoring processes for depression. Abundant support and guidance are available to pediatricians in depression care, including mental health consultation and online materials.

Depression Part 1: Evaluation

By young adulthood, 1 in 5 teens will experience an episode of major depression. The second leading cause of death among youths aged 15 to 24 years is suicide, most of which will have been caused by untreated or undiagnosed depression. Depression is a highly heritable condition: depressed children often have depressed parents. Support to caregivers is important because depressed parents can have negative effects on children's development and future mental health. Groups more vulnerable to mental health disorders such as depression include Black, Indigenous, and persons of color and lesbian, gay, bisexual, transgender, or queer/questioning, who in recent years have the highest rate of suicide attempts (Black teens, sexual minority youth), the highest increases in suicide rates (Black children and youths), and the highest suicide rates (American Indian/Alaskan native). They frequently experience more adverse childhood events, which increases the risk of depression and suicide attempts. Pediatricians are most likely to care for these vulnerable youths, who often are less engaged in specialty mental health care for a variety of reasons, including stigma and barriers to access. By offering behavioral and mental health care to vulnerable populations in primary care, mental health equity may be achieved. Screening for depression and assessment for suicide are within the scope of pediatric practice and among the competencies recommended by the American Academy of Pediatrics and The American Board of Pediatrics.

Measuring Population-Level Adolescent Mental Health Using a Single-Item Indicator of Experiences of Sadness and Hopelessness: Cross-Sectional Study

BACKGROUND

Population-level monitoring of adolescent mental health is a critical public health activity used to help define local, state, and federal priorities. The Youth Risk Behavior Surveillance System includes a single-item measure of experiences of sadness or hopelessness as an indicator of risk to mental health. In 2021, 42% of high school students reported having felt sad or hopeless for 2 weeks or more during the past 12 months. The high prevalence of US high school students with this experience has been highlighted in recent studies and media reports.

OBJECTIVE

This study seeks to examine associations between this single-item measure of experiences of sadness or hopelessness with other indicators of poor mental health including frequent mental distress and depressive symptoms.

METHODS

We analyzed survey data from a national sample of 737 adolescents aged 15-19 years as a part of the Teen and Parent Surveys of Health. Participants were recruited from AmeriSpeak, a probability-based panel designed to be representative of the US household population. Feeling sad or hopeless was operationalized as a "yes" response to the item, "During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?" Unadjusted and adjusted prevalence ratios (aPRs) were calculated to examine associations between the single-item measure of having felt sad or hopeless almost every day for 2 weeks with moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health. Adjusted models controlled for age, race and ethnicity, sex assigned at birth, and sexual identity.

RESULTS

Overall, 17.3% (unweighted: 138/735) of adolescents reported that they felt sad or hopeless for 2 weeks or more during the past 12 months, 30.2% (unweighted: 204/716) reported moderate to severe depressive symptoms, 18.4% (unweighted: 126/732) reported frequent mental distress, and 15.4% (unweighted: 107/735) reported functional limitation due to poor mental health. After adjusting for demographics, adolescents who reported that they felt sad or hopeless for 2 weeks or more were 3.3 times as likely to report moderate to severe depressive symptoms (aPR 3.28, 95% CI 2.39-4.50), 4.8 times as likely to indicate frequent mental distress (aPR 4.75, 95% CI 2.92-7.74), and 7.8 times as likely to indicate mental health usually or always interfered with their ability to do things (aPR 7.78, 95% CI 4.88-12.41).

CONCLUSIONS

Associations between having felt sad or hopeless for 2 weeks or more and moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health suggest the single-item indicator may represent relevant symptoms associated with poor mental health and be associated with unmet health needs. Findings suggest the single-item indicator provides a population-level snapshot of adolescent experiences of poor mental health.

Major challenges in youth psychopathology: treatment-resistant depression. A narrative review

Major depressive disorder (MDD) represents a major health issue in adolescents and young adults, leading to high levels of disability and profoundly impacting overall functioning. The clinical presentation of MDD in this vulnerable age group may slightly differ from what can be observed in adult populations, and psychopharmacological strategies do not always lead to optimal response. Resistance to antidepressant treatment has a prevalence estimated around 40% in youths suffering from MDD and is associated with higher comorbidity rates and suicidality. Several factors, encompassing biological, environmental, and clinical features, may contribute to the emergence of treatment-resistant depression (TRD) in adolescents and young adults. Furthermore, TRD may underpin the presence of an unrecognized bipolar diathesis, increasing the overall complexity of the clinical picture and posing major differential diagnosis challenges in the clinical practice. After summarizing current evidence on epidemiological and clinical correlates of TRD in adolescents and young adults, the present review also provides an overview of possible treatment strategies, including novel fast-acting antidepressants. Despite these pharmacological agents are promising in this population, their usage is expected to rely on risk-benefit ratio and to be considered in the context of integrated models of care.

Antidepressant Prescribing Practices of Pediatric Palliative Care Providers

Background: Mental health diagnoses can co-occur with complex medical illness in pediatric patients. Pediatricians may not feel comfortable with managing psychopharmacology for patients and access to child psychiatrists can be limited. Palliative care (PC) providers follow patients with serious illness longitudinally to address burdensome symptoms that affect quality of life and may be responsible for evaluation and treatment of mental health concerns; however, education in managing psychologic distress for pediatric palliative care (PPC) providers is limited. Objective: This study seeks to describe the antidepressant prescribing practices of PPC providers and describe their level of training and comfort in assessing for anxiety and depression and prescribing psychotropic medications. Methods: An electronic survey approved by the American Academy of Hospice and Palliative Medicine was distributed nationally to PPC providers. Results: A total of 58 providers responded to the survey (response rate 12.3%). Most reported prescribing a variety of antidepressants (79%). Very few used formal assessment tools to screen for depression (7%) or anxiety (16%). Less than a third of providers consulted child psychiatry before prescribing antidepressants (29%). More than half of providers (54.5%) had no formal training in assessment and treatment of anxiety and depression in pediatric patients. Despite this, many providers (70%) reported feeling comfortable in prescribing antidepressants while also endorsing interest in more training for behavioral health evaluation and treatment (82.5%). Conclusions: Limited training in assessing mental health concerns, prescribing, and managing psychopharmacology suggests an opportunity for more targeted education for pediatric PC providers regarding antidepressant prescribing practices.

Prospective Follow-Up of Adolescents With and at Risk for Depression: Protocol and Methods of the Identifying Depression Early in Adolescence Risk Stratified Cohort Longitudinal Assessments

Objective

To present the protocol and methods for the prospective longitudinal assessments-including clinical and digital phenotyping approaches-of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo) study, which comprises Brazilian adolescents stratified at baseline by risk of developing depression or presence of depression.

Method

Of 7,720 screened adolescents aged 14 to 16 years, we recruited 150 participants (75 boys, 75 girls) based on a composite risk score: 50 with low risk for developing depression (LR), 50 with high risk for developing depression (HR), and 50 with an active untreated major depressive episode (MDD). Three annual follow-up assessments were conducted, involving clinical measures (parent- and adolescent-reported questionnaires and psychiatrist assessments), active and passive data sensing via smartphones, and neurobiological measures (neuroimaging and biological material samples). Retention rates were 96% (Wave 1), 94% (Wave 2), and 88% (Wave 3), with no significant differences by sex or group (p > .05). Participants highlighted their familiarity with the research team and assessment process as a motivator for sustained engagement.

Discussion

This protocol relied on novel aspects, such as the use of a WhatsApp bot, which is particularly pertinent for low- to-middle-income countries, and the collection of information from diverse sources in a longitudinal design, encompassing clinical data, self-reports, parental reports, Global Positioning System (GPS) data, and ecological momentary assessments. The study engaged adolescents over an extensive period and demonstrated the feasibility of conducting a prospective follow-up study with a risk-enriched cohort of adolescents in a middle-income country, integrating mobile technology with traditional methodologies to enhance longitudinal data collection.

Managing major depressive disorder in adolescents in primary care

ABSTRACT

Major depressive disorder (MDD) remains a significant risk to adolescent health and well-being, recently amplified by the COVID-19 pandemic. Access to adolescent mental health care services remains challenging in many areas, resulting in many adolescents diagnosed with MDD remaining untreated. Primary care providers are becoming increasingly crucial in promptly diagnosing and treating this concern. Various clinical guidelines can support clinicians in developing strategies for screening, diagnosing, and managing a vulnerable population with MDD. Standardized screenings, algorithms, and treatment guidelines can help improve the quality of life and functional impairment of those with MDD.

Genetics, epigenetics, and neurobiology of childhood-onset depression: an umbrella review

Depression is a serious and persistent psychiatric disorder that commonly first manifests during childhood. Depression that starts in childhood is increasing in frequency, likely due both to evolutionary trends and to increased recognition of the disorder. In this umbrella review, we systematically searched the extant literature for genetic, epigenetic, and neurobiological factors that contribute to a childhood onset of depression. We searched PubMed, EMBASE, OVID/PsychInfo, and Google Scholar with the following inclusion criteria: (1) systematic review or meta-analysis from a peer-reviewed journal; (2) inclusion of a measure assessing early age of onset of depression; and (3) assessment of neurobiological, genetic, environmental, and epigenetic predictors of early onset depression. Findings from 89 systematic reviews of moderate to high quality suggest that childhood-onset depressive disorders have neurobiological, genetic, environmental, and epigenetic roots consistent with a diathesis-stress theory of depression. This review identified key putative markers that may be targeted for personalized clinical decision-making and provide important insights concerning candidate mechanisms that might underpin the early onset of depression.

The evidence-based COPE program: Reducing the time between diagnosing and treating depression and anxiety in youth

ABSTRACT

The soaring prevalence of depression and anxiety in children, teenagers, and young adults is now a public health epidemic, yet access to timely evidence-based mental health treatment is often lacking due to a severe shortage of mental health providers. This article provides an overview of the current state of depression and anxiety in children and adolescents as well as first-line evidence-based treatment. The Creating Opportunities for Personal Empowerment (COPE) program, a cognitive-behavioral skills-building intervention, is highlighted as an evidence-based intervention for timely treatment that can be delivered by NPs, physicians, and physician associates/assistants in primary care settings, school-based health centers, and chronic care clinics with reimbursement as well as in schools and universities as a preventive mental health intervention.

Psychotropic medication use among adolescents participating in three randomized trials of DBT

BACKGROUND

Frequently presenting with symptoms of mood or anxiety disorders, substance abuse or borderline personality disorder, suicidal and self-harming adolescents often are prescribed psychotropic medication. Though such treatment may be warranted, recurrent suicidal and self-harming behaviour is often linked to emotion dysregulation where pharmacological treatment has weak empirical support. There is a need for more clinical research into the frequency, type and rationale for pharmacological treatment in this group. In this secondary analysis of three randomized clinical trials of dialectical behaviour therapy for adolescents, we report on psychotropic medication use in the respective samples at the time of recruitment, compare use of psychotropic medication across trials and describe sample characteristics that may be associated with possible differences in psychotropic medication.

FINDINGS

Trials were conducted in Norway, the US and Spain (labelled the Oslo, US and Barcelona samples). At baseline, 86% of the Barcelona sample, 67% of the US sample and 12% of the Oslo sample were taking at least one psychotropic medication with antidepressants as the most frequent, followed by antipsychotics (72%, 22% and 1.3% respectively) and mood stabilizers (14.2%, 16.2% and 0%). In the Oslo sample there was a significant association between receiving a diagnosis of major depression and the likelihood of receiving antidepressants, but no such association was found in the Barcelona and US samples. The overall 7-8 times higher proportion of participants in the US and Barcelona samples treated with psychotropic medication could only partially be explained by differences between the samples in diagnostic profiles, symptom severity or level of dysfunction.

CONCLUSIONS

Highly prevalent in use among suicidal and self-harming adolescents with borderline features, psychotropic medication was still very unevenly prescribed across trials, differences not explained by differences in sample characteristics suggesting that current treatment practices are not fully empirically supported. We call for continued medical education and increased availability of evidence-based psychosocial interventions.

The prevalence of off-label use and supratherapeutic blood levels of outpatient psychotropic medication in suicidal adolescents

Introduction

Adolescents with mental disorders show an increased risk of suicidal phenomena. Vice versa, suicidality is a serious adverse event of psychotropic drug therapy in adolescents. There are only a few new psychotropic agents approved for this young age group. We evaluated the (pre-pandemic) prevalence of off-label use as well as detailed blood concentrations of outpatient psychotropic medication and sex differences in a clinical population of suicidal adolescents.

Methods

The urine presence and serum levels of psychotropic substances of adolescents hospitalized due to their acute suicidality but without a known actual suicide attempt (i.e., no acute intoxication or serious self-injuries) were investigated routinely between 01.03.2017 and 31.01.2018. Urine (N = 205) and blood samples (N = 193) were taken at the beginning of closed inpatient admission, i.e., the results of the laboratory analysis reflect outpatient drug intake. The serum levels of psychopharmacological medication and OTC medication were measured.

Results

Our sample consists of 231 cases (boys: N = 54; girls: N = 177, ratio: 1:3.3), aged 12-17 years (average age: 15,4 years). The most prevalent psychiatric diagnoses were depressive episodes (54%) and adjustment disorders (25%), and girls were more often diagnosed with depressive disorders than boys (boy/girl ratio: 1:9.5, p < 0.0001). More than half of adolescents (56%) used at least one prescribed psychotropic drug at admission (24.8% ≥ two psychotropic drugs). Off-label use of second-generation antipsychotics was significantly more frequent than off-label use of antidepressants (85% vs. 31%, p < 0.01). Adolescents suffering from depressive disorders were significantly more often on-label treated than adolescents with neurotic or stress-related disorders (56% vs. 10%). Female cases with prescribed psychotropic drug use showed significantly more frequent supratherapeutic drug levels than male cases (5% vs. 27%, p < 0.05).

Conclusion

Female adolescents may have an increased risk of supratherapeutic blood levels, especially when outpatient prescribed psychotropic drugs are off-label used. Measurement of blood levels of outpatient-prescribed psychotropic drugs could be used to enhance the safety and efficacy of the individual psychopharmacological treatment of adolescent suicidal patients. There is an urgent need for more real-world evidence on the effective treatment of adolescents with psychotropic drugs.

Measurement-Based Care for Depression in Youth: Practical Considerations for Selecting Measures to Assess Depression, Associated Features and Functioning

Identification and management of major depressive disorder (MDD) in children and adolescents remains a significant area of public health need. The process for identifying depression (e.g. screening) and management (e.g. measurement based care [MBC]) is substantially enhanced by utilization of clinical measures and rating scales. Measures can be self- or caregiver reported or clinician rated. They can aid recognition of at-risk individuals for future assessment and assist in clinical diagnosis and management of depression. In addition to assessing symptoms of depression, rating scales can be used to assess important associated features (e.g. anxiety, trauma) and functional outcomes (e.g. quality of life, performance/productivity). In this manuscript, we discuss practical considerations for clinicians and researchers when selecting rating instruments for assessing depression, associated factors, functioning, and treatment outcomes (i.e. adherence and side effects) as part of MBC in youth and provide a summary of rating scales commonly used in research and clinical settings.

Novel mechanism-based treatments for pediatric anxiety and depressive disorders

Pediatric anxiety and depressive disorders are common, can be highly impairing, and can persist despite the best available treatments. Here, we review research into novel treatments for childhood anxiety and depressive disorders designed to target underlying cognitive, emotional, and neural circuit mechanisms. We highlight three novel treatments lying along a continuum relating to clinical impact of the disorder and the intensity of clinical management required. We review cognitive training, which involves the lowest risk and may be applicable for problems with mild to moderate impact; psychotherapy, which includes a higher level of clinical involvement and may be sufficient for problems with moderate impact; and brain stimulation, which has the highest potential risks and is therefore most appropriate for problems with high impact. For each treatment, we review the specific underlying cognitive, emotional, and brain circuit mechanisms that are being targeted, whether treatments modify those underlying mechanisms, and efficacy in reducing symptoms. We conclude by highlighting future directions, including the importance of work that leverages developmental windows of high brain plasticity to time interventions to the specific epochs in childhood that have the largest and most enduring life-long impact.

Management of Premenstrual Disorders: ACOG Clinical Practice Guideline No. 7

PURPOSE

To provide recommendations for the management of premenstrual syndrome and premenstrual dysphoric disorder, collectively referred to as premenstrual disorders, based on assessment of the evidence regarding the safety and efficacy of available treatment options. An overview of the epidemiology, pathophysiology, and diagnosis of premenstrual disorders also is included to provide readers with relevant background information and context for the clinical recommendations.

TARGET POPULATION

Reproductive-aged adults and adolescents with premenstrual symptoms.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluations) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on the following evidence-based treatment options for premenstrual disorders, with an acknowledgement that many patients may benefit from a multimodal approach that combines several interventions: pharmacologic agents (hormonal and nonhormonal), psychological counseling, complementary and alternative treatments, exercise and nutritional therapies, patient education and self-help strategies, and surgical management. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence. Based on review of extrapolated data from adult populations and expert consensus, it was determined that the recommendations also apply to adolescents, with a few exceptions that are noted in the Clinical Practice Guideline.

What Do We Know About Depression Among Youth and How Can We Make Progress Toward Improved Understanding and Reducing Distress? A New Hope

This paper summarizes many findings about depression among children and adolescents. Depression is prevalent, highly distressing, and exerts considerable burden worldwide. Rates surge from childhood through young adulthood and have increased over the last decade. Many risk factors have been identified, and evidence-based interventions exist targeting mostly individual-level changes via psychological or pharmacological means. At the same time, the field appears stuck and has not achieved considerable progress in advancing scientific understanding of depression's features or delivering interventions to meet the challenge of youth depression's high and growing prevalence. This paper adopts several positions to address these challenges and move the field forward. First, we emphasize reinvigoration of construct validation approaches that may better characterize youth depression's phenomenological features and inform more valid and reliable assessments that can enhance scientific understanding and improve interventions for youth depression. To this end, history and philosophical principles affecting depression's conceptualization and measurement are considered. Second, we suggest expanding the range and targets of treatments and prevention efforts beyond current practice guidelines for evidence-based interventions. This broader suite of interventions includes structural- and system-level change focused at community and societal levels (e.g., evidence-based economic anti-poverty interventions) and personalized interventions with sufficient evidence base. We propose that by focusing on the FORCE (Fundamentals, Openness, Relationships, Constructs, Evidence), youth depression research can provide new hope.

Current strategies for tapering psychiatric drugs: Differing recommendations, impractical doses, and other barriers

While effective ways to prevent withdrawal symptoms from psychiatric drugs remain unclear, a highly accepted clinical approach for treatment discontinuation is to gradually reduce doses over time. The objective of this review is to gather the current strategies for tapering of psychiatric drugs described in the literature and guidelines in an attempt to identify the most promising one. Literature review and search for practice guidelines provided by government agencies and medical organizations were performed. Different strategies for tapering were found: linear tapering, hyperbolic tapering (by exponential dose reduction and pre-established dose-response curves), extended dosing, and substitution for a long half-life drug. The use of guidelines offers support for patients and prescribers, increasing the likelihood of achieving effective drug discontinuation. Nevertheless, the lack of standardization found among the guidelines makes any attempt to reduce or stop the drug very difficult for prescribers. Hyperbolic tapering by exponential dose reduction appears to be the most promising strategy for psychiatric drug discontinuation. Yet, we still face a constant challenge: how to safely obtain flexible doses for the discontinuation of drugs, particularly during the last steps in which lower doses are required. Further studies are needed to reduce the barriers associated with psychiatric drug discontinuation.

Mental Health in the Specialized Athlete

PURPOSE OF REVIEW

The aim of this review is to interpret the existing evidence regarding the psychological aspects of sport specialization within the context of a developmental framework.

RECENT FINDINGS

The growing trend toward early sport specialization is associated with increased risk for injury and burnout, both of which have significant implications for mental health. Mental health literacy programs designed to promote awareness, decrease stigma, and encourage help-seeking behaviors can be an effective way to increase resilience and early recognition of those in need. The trend toward early sport specialization is likely motivated in large part by the expectation that it will increase the likelihood of long-term athletic success. However, recent studies suggest that the majority of elite athletes delay specialization at least until mid to late adolescence. It is essential to consider the developmental psychology of children and adolescents and to avoid imposing expectations that are beyond their neurocognitive capabilities. In addition to depression, anxiety, and burnout, young athletes who are pressured to perform to excessively high standards are likely to internalize athletic failures as feelings of shame. This can lead to maladaptive perfectionistic traits and potentially overtraining, clinical eating disorders, or other harmful behaviors that will result in declines in performance, physical health, and overall wellbeing. Further work is needed to better inform sport-specific recommendations regarding sport specialization and to optimize the beneficial effects of sport participation while limiting the risks of harm.

State of the Evidence for Use of Psychotropic Medications in School-Age Youth

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

Major depressive disorder

Major depressive disorder (MDD) is characterized by persistent depressed mood, loss of interest or pleasure in previously enjoyable activities, recurrent thoughts of death, and physical and cognitive symptoms. People with MDD can have reduced quality of life owing to the disorder itself as well as related medical comorbidities, social factors, and impaired functional outcomes. MDD is a complex disorder that cannot be fully explained by any one single established biological or environmental pathway. Instead, MDD seems to be caused by a combination of genetic, environmental, psychological and biological factors. Treatment for MDD commonly involves pharmacological therapy with antidepressant medications, psychotherapy or a combination of both. In people with severe and/or treatment-resistant MDD, other biological therapies, such as electroconvulsive therapy, may also be offered.

Factors Related to Placebo Response in Randomized, Double-Blind Clinical Trials of Antidepressants in Children and Adolescents: A Meta-regression Analysis

BACKGROUND AND OBJECTIVE

Many randomized clinical trials (RCTs) for antidepressants in children and adolescents have failed to demonstrate efficacy due to a high placebo response. The aim of this study was to identify the potential factors affecting placebo response using meta-regression analysis of RCTs for antidepressants in children and adolescents using the Children's Depressive Rating Scale-Revised (CDRS-R) as the outcome.

METHODS

PubMed and ClinicalTrials.gov were searched for randomized, double-blind, placebo-controlled trials of antidepressants for the acute treatment of major depressive disorder in children and adolescents. The outcome used in the present study was the mean change of the CDRS-R total score from baseline to the last assessment for the primary efficacy in the placebo arm. Potential factors related to the placebo response, such as study design, operational, and patient factors, were explored using meta-regression.

RESULTS

The analyses included 23 trials. On multivariable meta-regression, setting up a placebo lead-in period was significantly associated with a smaller placebo response in the CDRS-R.

CONCLUSION

Setting up a placebo lead-in period should be considered in future clinical trials of antidepressants in adolescents and children.