Annual Research Review: Sex, gender, and internalizing conditions among adolescents in the 21st century - trends, causes, consequences

Neural Circuit Mechanisms of Sinisan formula for the Treatment of adolescent Depression: prefrontal cortex to dorsal raphe nucleus

ETHNOPHARMACOLOGICAL RELEVANCE

Sinisan formula (SNSF), documented in the classic books Shanghan Lun, is known for its ability to regulate liver-qi and treat depression. However, its underlying mechanism, particularly its effects on dynamic real-time neuron activity and circuits remains to be fully elucidated.

AIM OF THE STUDY

This study aimed to investigate the antidepressant effect of SNSF and its central nervous system mechanism on depression-like behaviors, focusing on the prefrontal cortex (PFC) to dorsal raphe nucleus (DRN) neural circuit in a stress-induced adolescent animal model.

MATERIALS AND METHODS

SNSF comprised four herbs, the root of Bupleurum chinense DC., the root of Paeonia lactiflora Pall., the fruit of Citrus aurantium L., the rhizome of Glycyrrhiza uralensis Fisch., in equal propotions. The adolescent depression animal model was induced by maternal separation (MS) and chronic restraint stress (CRS). In-vivo multichannel physiological electrodes were implanted into the PFC on PND 28 and animals were recorded 5 times during PND 35-46. From PND 47, the behavioral tests were performed to evaluate the antidepressant efficacy of SNSF. Subsequently, brain tissue was collected for Western blot and immunofluorescence staining analysis. Retro virus was injected into the DRN to explore sources of projections received by serotonergic (5-HTergic) neurons. And the PFC-to-DRN circuit was activated or inhibited through chemogenetic techniques to investigate the effects of SNSF on depression-like behaviors.

RESULTS

Administration of SNSF for 18 days effectively alleviated depression-like behaviors in MS&CRS adolescent mice. The PFC emerged as the primary glutamatergic projection source of the DRN5-HT neurons. Following SNSF administration for 13/15/18 days, there was an increase in the firing rate of excitatory neurons and excitatory/inhibitory (E/I) ratio in the PFC. MS&CRS stress let to a reduction in the density of 5-HT+ and CaMKII + neurons in the DRN, accompanied by an increase in the density of GAD + neurons in the DRN, while SNSF administration reversed the alterations. Chemogenetic activation of the PFC-to-DRN circuit rescued the depression-like behaviors induced by MS&CRS, whereas suppression of this circuit attenuated the antidepressant effect of SNSF.

CONCLUSIONS

SNSF significantly mitigated depression-like behaviors in MS&CRS mice. SNSF exerts its antidepressant effects by increasing the E/I ratio in the PFC and enhancing glutamatergic projections from the PFC to the DRN.

The Depression Anxiety Stress Scales for Youth (DASS-Y): evidence of validity and cross-national and gender measurement invariance

The Depression Anxiety Stress Scales for Youth (DASS-Y) is a recently developed measure of unpleasant emotional experiences for children and adolescents; however, the evidence for its validity is still limited. The present study evaluated the evidence for the structural, convergent, and incremental validity of the DASS-Y on a sample of Serbian adolescents aged 15-19 years (N = 421; 48% female, mean age = 16.86). Measurement invariance across gender and two countries (Serbia and Australia) was also tested. The findings supported the bifactor exploratory structural equation modeling (bifactor-ESEM) representation of the DASS-Y, which includes the General factor of negative affect/emotional distress, and three specific factors of Depression, Anxiety, and Stress. The DASS-Y factors showed evidence of incremental validity in predicting global externalizing symptoms and demonstrated convergent validity in relation to measures of global internalizing and externalizing symptoms as well as subjective well-being. The bifactor-ESEM model of the DASS-Y was found to be invariant across gender and two countries. The present study findings highlight the importance of distinguishing between general and specific components of unpleasant emotional states.

Psychometric validation of the Montgomery-åsberg Depression Rating Scale - Youth (MADRS-Y) in a clinical sample

BACKGROUND

Depression in adolescence is a serious major global health problem with increasing rates of prevalence. Measures of depression that are valid for young people are clearly needed in clinical contexts.

METHODS

The study included 577 patients from child and adolescent psychiatry (n = 471) and primary care (n = 106) aged 12-22 years in Sweden (Mage=16.7 years; 76% female). The reliability and validity for Montgomery-Åsberg Depression Rating Scale - Youth (MADRS-Y) were investigated. To confirm the latent structure, we used a single-factor confirmatory factor analysis (CFA). A Kruskal-Wallis test was performed to test total score differences between diagnostic groups. Using Spearman's rho correlations, we examine whether single items in the MADRS-Y correlate with suicidal ideation measured by The Suicidal Ideation Questionnaire-JR (SIQ-JR).

RESULTS

The internal consistency using McDonald's coefficient omega was excellent. The CFA of the 12-item MADRS-Y supported a one factor structure. Evidence of convergent and discriminant validity was shown. There was a significant difference in MADRS-Y scores across diagnostic groups, with higher results for depressive disorders. A strong correlation with suicidal ideation was found for two items.

CONCLUSIONS

The results support MADRS-Y as a brief, reliable, and valid self-report questionnaire of depressive symptoms for young patients in a clinical setting.

Association between adolescent depression and adult suicidal behavior: A systematic review and meta-analysis

This meta-analysis aims to estimate the association between adolescent depression and adult suicidal behavior, while systematically evaluating gender differences reported in literature. A random-effects model was used to determine the pooled association, reporting odds ratios (ORs) with corresponding 95 % confidence intervals (CIs). Nine articles comprising over 6084 adolescents together showed that people with a history of depression in adolescence are more likely to gain suicidal behaviors during adulthood (OR = 3.97, 95 % Cl: 2.79, 5.63). Sex-specific analysis indicated that males who experienced depression in adolescence developed a higher incidence of suicidal behavior in adulthood compared to females with a similar history (Males: OR = 3.61, 95 % Cl: 1.02, 12.78; Females: OR = 3.56, 95 % Cl: 1.71, 7.43). Furthermore, suicide attempts emerged as the predominant outcome among various suicidal behaviors (OR = 3.43, 95 % Cl: 1.75, 6.71). This meta-analysis provides robust evidence that depression in adolescence significantly increases the risk of suicidal behavior in adulthood.

The mediating effect of after-midnight use of digital media devices on the association of internet-related addictive behavior and insomnia in adolescents

Background

There is evidence that overexposure to digital media devices (DMD) can not only lead to addictive patterns of internet use, but also cause insomnia symptoms. The aim of this cross-sectional study among adolescents is to provide an estimate of the prevalence of sleep impairments and to explore the mediating role of after-midnight use of DMD between internet-related addictive behavior (IRAB) and insomnia.

Methods

2,712 school students from Styrian schools participated in a population-representative online survey in a supervised school setting in spring 2022. School students were screened using established and validated scales. Data analysis was carried out using multiple imputation, linear multilevel regression and mediation analysis.

Results

Prevalence estimation indicates high proportions of clinically relevant moderate [12.6% (11.3%; 14.1%)] and severe [3.6% (2.9%; 4.4%)] insomnia, with an additional 30.6% (29.0%; 32.2%) at subthreshold level. DMD are typically used after midnight an average of 1.66 (1.58; 1.75) evenings with subsequent school day per school week. Linear multilevel regression analysis shows significant associations for sleep disparities as outcome variable e.g., with generalized anxiety [b = 0.329 (0.287; 0.371)], after-midnight use of DMD [b = 0.470 (0.369; 0.572)] and IRAB [b = 0.131 (0.097; 0.165)]. Mediation analysis shows a mediated proportion of 18.2% (13.0%; 25.0%) of the association of IRAB and insomnia by after-midnight use of DMD [Indirect effect: b = 0.032 (0.023; 0.040), direct effect: b = 0.127 (0.083; 0.170)].

Conclusions

Although the cross-sectional nature of this study limits causal inference, the results indicate a need for policies, which are already in preparation in Styria as part of a respective action plan.

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.

Twenty-year changes of adolescent mental health and substance use: a Finnish population-based time-trend study

This time-trend study assesses changes in mental health and substance use among Finnish adolescents from 1998 to 2018. Representative samples of adolescents (N = 6,600) aged 13-16 years participated in school-based, almost identical cross-sectional studies in 1998 (n = 1,446), 2008 (n = 2,009), 2014 (n = 1,800) and 2018 (n = 1,345), respectively. The Strengths and Difficulties Questionnaire was used to assess mental health. When comparing mental health in the clinical range between 1998 and 2018, the main finding was the significant increase of emotional symptoms among females. The percentage of females in the clinical range increased from 17.5 to 30.1% during the twenty-year period. When psychopathology measures were analyzed as continuous variables, the finding of increased emotional problems was confirmed. The study clearly illustrates a linear trend, with a consistent increase in emotional problems among females and decrease in substance use among both genders. An alarming finding of steady increase of self-reported emotional problems indicates the importance of early detection and evidence-based interventions for adolescent with anxiety and depression to prevent adversities associated with these disorders.

The COVID-19 pandemic and wellbeing in Switzerland-worse for young people?

BACKGROUND

The key objective of our study was to describe the population-average trajectories of wellbeing, spanning the period of 2017-2022, comparing young people with other age groups. Moreover, we aimed to identify subgroups of young people who experienced disproportionate changes in wellbeing.

METHODS

We used longitudinal data from six waves (2017-2022) of the Swiss Household Panel. Participants were at least 14 years old in 2017 and had at least one valid composite measure of wellbeing between 2017 and 2022 (n individuals = 11,224; n observations = 49,032). The data were typically collected with telephone or web interviewing. The age of participants ranged from 14 to 102, with a roughly equal distribution of men (51.1%) and women (48.9%). We conceptualized wellbeing as positive affect and life satisfaction, negative affect, stress and psychosomatic symptoms. We described the trajectories of wellbeing using piecewise growth curve analysis. We included sociodemographic characteristics to further describe wellbeing trajectories across subgroups of young people. These comprised (1) gender, (2) migration status, (3) partnership status, (4) living with parents, (5) education/employment status, (6) household income.

RESULTS

Young people (age 14-25) experienced a steady decline in positive affect and life satisfaction throughout the entire period, with the greatest change occurring before the pandemic (2017-2019). The trajectories in this outcome were largely stable in other age groups. Moreover, young individuals showed a more pronounced increase in negative affect, particularly in the pre-pandemic years, compared to older groups. Negative affect increased during the pandemic, followed by a subsequent decline post-pandemic, observed similarly across all age groups. Among young people specifically, the trajectory of stress was similar to the one of negative affect. However, issues such as sleep problems, weakness, weariness, and headaches continued to increase in this population from 2017 to 2022. We also found evidence for a greater increase in negative affect during the pandemic in young women and those not in employment or education.

CONCLUSIONS

Given the fact that the decline in young people's wellbeing in Switzerland started two years before the pandemic, our study emphasises the importance of consideing their wellbeing within a broader systemic context beyond pandemic-related changes.

Temporal trends in inpatient care use for adult mental disorders in Czechia: a nationwide register-based study from 1994 to 2015

PURPOSE

To describe temporal trends in inpatient care use for adult mental disorders in Czechia from 1994 until 2015.

METHODS

Data from the nationwide register of inpatient care use and yearly census data were used to calculate (a) yearly admissions rates, (b) median length of stay, and (c) standardized inpatient-years for adult mental disorders (ICD-10 codes F0-F6] or G30). Segmented regressions were used to analyze age- and sex-specific temporal trends.

RESULTS

Admission rates were increasing in adults (average annual percent change = 0.51; 95% confidence interval = 0.16 to 0.86 for females and 1.01; 0.63 to 1.40 for males) and adolescents and emerging adults (3.27; 2.57 to 3.97 for females and 2.98; 2.08 to 3.88 for males), whereas in seniors, the trend was stable (1.22; -0.31 to 2.73 for females and 1.35; -0.30 to 2.98 for males). The median length of stay for studied mental disorders decreased across all age and sex strata except for a stable trend in male adolescents and emerging adults (-0.96; -2.02 to 0.10). Standardized inpatient-years were decreasing in adults of both sexes (-0.85; -1.42 to -0.28 for females and -0.87; -1.19 to -0.56 for males), increasing in female adolescents and emerging adults (0.95; 0.42 to 1.47), and stable in the remaining strata.

CONCLUSION

Psychiatric hospital admissions were increasing or stable coupled with considerable reductions in median length of stay, suggesting that inpatient episodes for adult mental disorders have become more frequent and shorter over time. The overall psychiatric inpatient care use was decreasing or stable in adults and seniors, potentially implying a gradual shift away from hospital-based care.

Commentary: Integrative, multi-level explanatory models are needed to understand recent trends in sex, gender, and internalizing conditions, reflections on Keyes and Platt (2023)

Keyes' and Platt's (The Journal of Child Psychology and Psychiatry, 2023) review provides much-needed systematic evidence about why internalizing symptoms have increased and it clarifies the role of novel risk factors. The findings highlight that multiple factors at multiple levels are responsible for this phenomenon, many with small effects, within a complex interplay that is rarely well captured. As new insights emerge across disciplines, an important step is to renew efforts to integrate them to understand how internalizing symptoms develop for different people.

Novel rapid treatment options for adolescent depression

There is an urgent need for novel fast-acting antidepressants for adolescent treatment-resistant depression and/or suicidal risk, since the selective serotonin reuptake inhibitors that are clinically approved for that age (i.e., fluoxetine or escitalopram) take weeks to work. In this context, one of the main research lines of our group is to characterize at the preclinical level novel approaches for rapid-acting antidepressants for adolescence. The present review summarizes the potential use in adolescence of non-pharmacological options, such as neuromodulators (electroconvulsive therapy and other innovative types of brain stimulation), as well as pharmacological options, including consciousness-altering drugs (mainly ketamine but also classical psychedelics) and cannabinoids (i.e., cannabidiol), with promising fast-acting responses. Following a brief analytical explanation of adolescent depression, we present a general introduction for each therapeutical approach together with the clinical evidence supporting its potential beneficial use in adolescence (mainly extrapolated from prior successful examples for adults), to then report recent and/or ongoing preclinical studies that will aid in improving the inclusion of these therapies in the clinic, by considering potential sex-, age-, and dose-related differences, and/or other factors that might affect efficacy or long-term safety. Finally, we conclude the review by providing future avenues to maximize treatment response, including the need for more clinical studies and the importance of designing and/or testing novel treatment options that are safe and fast-acting for adolescent depression.

Integrating mental health into climate change education to inspire climate action while safeguarding mental health

Climate change is the greatest threat humanity faces, and puts at risk the mental health and wellbeing of children and young people. Climate change education must equip children and young people with the knowledge, skills and resilience to live in an uncertain future, sustainably take relevant climate action and work in climate careers. As attention on climate change education grows, this is a critical moment for the mental health community to ensure mental health and wellbeing considerations are embedded. Critically, appropriate integration of mental health can enable these very necessary goals of equipping children and young people to live and work in a future where climate change looms large. This paper explores why promoting good mental health and wellbeing and building psychological resilience can help achieve climate change education outcomes, and why not doing so risks harming children and young people's mental health. It also explores how integrating discussions about emotions, mental health, and coping strategies within climate change education can be a route into wider discussions about mental health, to support children and young people in the context of rising mental health needs. Learning from an existing approach to promoting good mental health and wellbeing in schools (the 'whole school approach') provides the opportunity to explore one avenue through which such an integrated approach could be implemented in practice. Identifying appropriate mechanisms to integrate mental health into climate change education will require co-design and research with educators and young people, and addressing systemic barriers facing the schools sector.

Trends in Suicidal Mortality and Motives among Working-Ages Individuals in Japan during 2007-2022

Suicides in Japan consistently decreased from 2009-2019, but increased during the COVID-19 pandemic. To identify causes of increasing suicides, age-dependent and temporal fluctuations of suicide mortality rate per 100,000 (SMRP) in working-age generations (20-59 years) disaggregated by suicidal motives (7-categories; 52-subcategories) and sex from 2007 to 2022, were analyzed by analysis of variance and joinpoint regression, respectively, using the government suicide database "Suicide Statistics". The SMRP of 20-29 year-old males and 20-49 year-old females began to increase in the late 2010s. SMRPs of these high-risk groups for suicides caused by depression (the leading suicidal motive for all groups) began increasing in the late 2010s. Economic-related, employment-related, and romance-related problems contributed to the increasing SMRPs in 20-29 males in the late 2010s. Romance-related and family-related problems contributed to the increasing SMRPs of 20-29 females in the late 2010s. Increasing SMRPs caused by child-raising stress in 20-39 year-old females from the late 2010s was a remarkable finding. In contrast, SMRPs of 30-59 year-old males consistently decreased until 2021; however, in these groups, SMRPs for suicides caused by various motives sharply increased in 2022. The consistent increase in SMRPs of high-risk groups from the late 2010s to the pandemic suggest recent socioeconomic and psychosocial problems in Japan possibly contributed to the increasing SMRPs in these high-risk groups independently of pandemic-associated factors, whereas the SMRPs of males of 30-59 years were probably associated with the ending of the pandemic rather than pandemic-associated factors.

Electroconvulsive seizures regulate various stages of hippocampal cell genesis and mBDNF at different times after treatment in adolescent and adult rats of both sexes

Electroconvulsive therapy, a fast-acting option for treatment-resistant depression, is modeled at the preclinical level through the induction of electroconvulsive seizures (ECS) in rodents. Recent studies from our group proved sex- and age-differences in the antidepressant-like response elicited by ECS in rats; while an antidepressant-like response was observed in male adolescent and adult rats (although with greater efficacy in adulthood), the same parameters rendered inefficacious in females of any age. To better understand the potential sex differences taking place at the molecular level that might be mediating these behavioral disparities, we evaluated the impact of a repeated treatment with ECS (95 mA for 0.6 s, 100 Hz, 0.6 ms) in adolescent and adult rats of both sexes. Several hippocampal markers of neuroplasticity, commonly regulated by most antidepressants, such as those of neurogenesis (cell proliferation, neurogenic differentiation, long-term cell survival) or mBDNF and associated signaling (e.g., mTOR and ERK1/2) were evaluated at different time-points after treatment (1-, 8-, 15- and up to 30-days post-treatment). The main results demonstrated that ECS improved the survival rate of new cells born in the dentate gryus before treatment. Moreover, ECS increased cell proliferation and neurogenic differentiation at different times post-treatment, paired with persistent increases in mBDNF, observed long after treatment. In general, effects were different for each sex and varied with the age of the animal (adolescent vs. adulthood). The present study is the first-one to demonstrate that such persistent molecular changes induced by ECS in hippocampus, some of them observed up to 30-days post-treatment, also occurred in female rats and adolescence. Although these molecular changes could not justify the lack of ECS efficacy described by these same parameters of ECS in female rats (vs. male rats), they proposed certain beneficial effects common to both sexes, and age periods studied, opening the avenue for further studies. Based on these neurochemical effects, ECS should have displayed similar efficacies for both biological sexes. Therefore, the reason behind these disparities should be further explored to better translate efficacious treatments specific and/or personalized for each sex to the clinic.