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The Burden of Depression in Adolescents and the Importance of Early Recognition

2020; Elsevier BV; Volume: 218; Linguagem: Inglês

10.1016/j.jpeds.2019.12.003

1097-6833

Annamaria Petito, Tudor Lucian Pop, Leyla S. Namazova-Baranova, Julije Meštrović, Luigi Nigri, Mehmet Vural, Michele Sacco, Ida Giardino, Pietro Ferrara, Massimo Pettoello‐Mantovani,

Child and Adolescent Psychosocial and Emotional Development

Mental health disorders are frequent during the developmental years, particularly in adolescents. The leading cause of disability in young people are neuropsychiatric conditions, which if left untreated may severely affect development, including educational and social achievements. It has been reported that 10%-20% of individuals experience a form of mental disorder during childhood and adolescence worldwide.1WHOReport on Adolescent Mental health (October 23, 2019).www.who.int/news-room/fact-sheets/detail/adolescent-mental-healthDate accessed: November 16, 2019Google Scholar One-half of them arise by 14 years of age.2Lopez A. Mathers C. Ezzati M. Jamison D. Murray C. Global burden of disease and risk factors. Oxford University Press and the World Bank, Washington (DC)2006Crossref Google Scholar Among adolescent mental health disorders, depression is one of the most frequent conditions, and it is indicated as one of the most alarming “new morbidities.”3American Academy of PediatricsAmerican Academy of Pediatrics the new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care. Committee on Psychosocial Aspects of Child and Family Health.Pediatrics. 2001; 108: 1227-1230Crossref PubMed Scopus (109) Google Scholar,4Windfuhr K. While D. Hunt I. Turnbull P. Lowe R. Burns J. et al.National confidential inquiry into suicide and homicide by people with mental illness. Suicide in juveniles and adolescents in the United Kingdom.J Child Psychol Psychiatry. 2008; 49: 1155-1165Crossref PubMed Scopus (99) Google Scholar The onset of depression is typically around mid-to-late adolescence, and it important to recognize its early warning signs and symptoms. Early intervention can often prevent the later development of a severe depressive illness. For instance, in adolescents, depression is a major risk factor for suicide, and more than one-half of adolescent suicide victims were reported to have a depressive disorder at the time of death.5Hawton K. van Heeringen K. Suicide.Lancet. 2009; 373: 1372-1381Abstract Full Text Full Text PDF PubMed Scopus (1287) Google Scholar Depression also leads to serious social and educational maladjustments in this age group, such as an increased rate of smoking, substance misuse, eating disorders, and obesity.6Lewinsohn P.M. Rohde P. Seeley J.R. Major depressive disorder in older adolescents: prevalence, risk factors and clinical implications.Clin Psychol Rev. 1988; 18: 765-794Crossref Scopus (749) Google Scholar,7Keenan-Miller D. Hammen C.L. Brennan P.A. Health outcomes related to early adolescent depression.J Adolesc Health. 2007; 41: 256-262Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar This commentary aims to further raise awareness of pediatricians on the burden and risks faced by adolescents developing depression. In particular, we emphasize that new morbidities should be part of the formal training in pediatrics worldwide, enabling the new generations of pediatricians to recognize these pathologic conditions in a timely manner and effectively deal with them. Depression is identified by a cluster of specific symptoms with associated harms (Table I; available at www.jpeds.com). Adolescents and adults show similar clinical and diagnostic elements.8Thapar A. Collishaw S. Potter R. Thapar A.K. Managing and preventing depression in adolescents.BMJ. 2010; 340: c209Crossref PubMed Scopus (43) Google Scholar,9Lewinsohn P.M. Pettit J.W. Joiner Jr., T.E. Seeley J.R. The symptomatic expression of major depressive disorder in adolescents and young adults.J Abnorm Psychol. 2003; 112: 244-252Crossref PubMed Scopus (122) Google Scholar Depression in children is relatively infrequent; the prevalence is reported to be less than 1% in most studies, rising substantially throughout adolescence.10Kessler R.C. Avenevoli S. Ries Merikangas K. Mood disorders in children and adolescents: an epidemiologic perspective.Biol Psychiatry. 2001; 49: 1002-1014Abstract Full Text Full Text PDF PubMed Scopus (792) Google Scholar,11Green H. McGinnity A. Meltzer H. Ford T. Goodman R. Mental health of children and young people in Great Britain, 2004. Palgrave Macmillan, Basingstoke, UK2005Crossref Google Scholar The postpubertal increase in the prevalence of depression can be explained by several factors related to the marked biological and social changes characterizing this developmental period. Among them, puberty, brain, and cognitive maturation have been frequently reported, together with the enhanced social understanding, sensibility, sensitivity, and self-awareness typical of this age period.12Patton G.C. Viner R. Pubertal transitions in health.Lancet. 2007; 369: 1130-1139Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar, 13Cyranowski J.M. Frank E. Young E. Shear K. Adolescent onset of the gender difference in lifetime rates of major depression.Arch Gen Psychiatry. 2000; 57: 21-27Crossref PubMed Scopus (785) Google Scholar, 14Blakemore S.J. The social brain in adolescence.Nat Rev Neurosci. 2008; 9: 267-277Crossref PubMed Scopus (950) Google Scholar Neurophysiologic changes have a role in the unbalanced responses to reward and danger, and escalating feelings of stress and anxiety are registered, particularly in adolescent girls.15Silberg J. Pickles A. Rutter M. et al.The influence of genetic factors and life stress on depression among adolescent girls.Arch Gen Psychiatry. 1999; 56: 225-232Crossref PubMed Scopus (310) Google Scholar,16Nelson E.E. Leibenluft E. McClure E.B. Pine D.S. The social re-orientation of adolescence: a neuroscience perspective on the process and its relation to psychopathology.Psychol Med. 2005; 35: 163-174Crossref PubMed Scopus (650) Google Scholar The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes a cross-cultural assessment of depression and an updated classification, providing a list of diagnostic symptoms.17American Psychiatric AssociationDiagnostic and statistical manual of mental disorders.5th ed. American Psychiatric Association, Arlington (VA)2013Crossref Google Scholar As described in the DSM-5, major depressive disorders are characterized by marked episodes of a minimum 2 weeks' duration with at least 1 of 2 symptoms, which could be either depressed mood, loss of interest or pleasure, or alterations in affect and emotions, cognition, and neurovegetative functions.17American Psychiatric AssociationDiagnostic and statistical manual of mental disorders.5th ed. American Psychiatric Association, Arlington (VA)2013Crossref Google Scholar Although the presence of a single episode could be sufficient to establish the diagnosis, in the majority of cases, this disorder is characterized by recurrent episodes alternating with remissions. The 2 main classification systems (DSM-5 and the International Classification of Diseases-11) define depression similarly, although in the DSM-5 irritability rather than depressed mood is accepted as a core diagnostic symptom.17American Psychiatric AssociationDiagnostic and statistical manual of mental disorders.5th ed. American Psychiatric Association, Arlington (VA)2013Crossref Google Scholar,18WHOInternational classification of diseases, 11th revision. The global standard for diagnostic health information.https://icd.who.int/enDate accessed: November 13, 2019Google Scholar Depression in adolescents is frequently missed, possibly owing to the prevalence of irritability, mood instability, reactivity, and oscillating symptoms in this age group compared with adults.19Leaf P.J. Alegria M. Cohen P. Goodman S.H. Horwitz S.M. Hoven C.W. et al.Mental health service use in the community and schools: results from the four-community MECA Study. Methods for the epidemiology of child and adolescent mental disorders study.J Am Acad Child Adolesc Psychiatry. 1996; 35: 889-897Abstract Full Text PDF PubMed Scopus (482) Google Scholar However, depression can also be missed owing to a number of different initial problems, including unexplained physical symptoms, eating disorders, anxiety, misconduct, refusal to attend school, decline in academic performance, and substance misuse. Population prevalence estimates for depression vary widely across studies and between different countries, possibly owing to the different classifications adopted, diagnostic procedures, and study methods.20Fleitlich-Bilyk B. Goodman R. Prevalence of child and adolescent psychiatric disorders in southeast Brazil.J Am Acad Child Adolesc Psychiatry. 2004; 43: 727-734Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar,21Pillai A. Patel V. Cardozo P. Goodman R. Weiss H.A. Andrew G. Non-traditional lifestyles and prevalence of mental disorders in adolescents in Goa, India.Br J Psychiatry. 2008; 192: 45-51Crossref PubMed Scopus (79) Google Scholar The median 12-month prevalence rates (4%-5%), found in mid-to-late adolescence are similar to those observed in adults.3American Academy of PediatricsAmerican Academy of Pediatrics the new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care. Committee on Psychosocial Aspects of Child and Family Health.Pediatrics. 2001; 108: 1227-1230Crossref PubMed Scopus (109) Google Scholar,22Lewinsohn P.M. Rohde P. Klein D.N. Seeley J.R. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood.J Am Acad Child Adolesc Psychiatry. 1999; 38: 56-63Abstract Full Text PDF PubMed Scopus (420) Google Scholar However, the aggregated published data show that the probability of depression rises from about 5% in early adolescence to as high as 20% by the end of this age period.6Lewinsohn P.M. Rohde P. Seeley J.R. Major depressive disorder in older adolescents: prevalence, risk factors and clinical implications.Clin Psychol Rev. 1988; 18: 765-794Crossref Scopus (749) Google Scholar,22Lewinsohn P.M. Rohde P. Klein D.N. Seeley J.R. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood.J Am Acad Child Adolesc Psychiatry. 1999; 38: 56-63Abstract Full Text PDF PubMed Scopus (420) Google Scholar Depression typically leads individuals to become isolated from family and friends and to hazardous behaviors, such as irresponsible driving, alcohol and substance abuse, and inappropriate sexual behaviors. The burden of depression on adolescents' health and social functioning could be severe and influence their adult life. Especially among the youngest children and adolescents, signs of depression are too often unrecognized, disregarded, overlooked, or purposely ignored by the family and by the primary care provider. This factor may represent a major obstacle in establishing timely effective preventive measures. Depression in young children up to 6 years of age usually presents in minor or masked forms.10Kessler R.C. Avenevoli S. Ries Merikangas K. Mood disorders in children and adolescents: an epidemiologic perspective.Biol Psychiatry. 2001; 49: 1002-1014Abstract Full Text Full Text PDF PubMed Scopus (792) Google Scholar In these cases, the recurrent symptomatology concerns the psychosomatic sphere, including problems with the sleep-wake rhythm and nutrition, possibly accompanied by dermatologic and respiratory problems. Very young children can experience a particular form of depression involving interpersonal dependency, which is characterized by intense fears of abandonment and feelings of helplessness and weakness. At the base of this form of depression usually lies a family affective disorder, such as the absence of the mother or the father owing to illness, the death of one of the parents, or the loss of a close adult figure. Affective loss owing to separation from parents or other figures could also be caused by the child's disease and prolonged hospital admissions.23Pettoello-Mantovani M. Pop T.L. Mestrovic J. Ferrara P. Giardino I. Carrasco-Sanz A. et al.Fostering resilience in children: the essential role of healthcare professionals and families.J Pediatr. 2019; 205: 298-299.e1Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar With the growth and stabilization of emotional states, through social interactions within the family, in kindergarten, and later during primary school, the child may be able to develop compensatory mechanisms that can mitigate an initial depressive state. An important alarming sign predictive of a depressive state in children during primary school age is mood instability, with rapid oscillations of intense affect, and difficulty in regulating these oscillations and their behavioral consequences, rapidly switching from laughter to tears.10Kessler R.C. Avenevoli S. Ries Merikangas K. Mood disorders in children and adolescents: an epidemiologic perspective.Biol Psychiatry. 2001; 49: 1002-1014Abstract Full Text Full Text PDF PubMed Scopus (792) Google Scholar,11Green H. McGinnity A. Meltzer H. Ford T. Goodman R. Mental health of children and young people in Great Britain, 2004. Palgrave Macmillan, Basingstoke, UK2005Crossref Google Scholar The family environment represents a significant variable in the development of the child's depressed personality. Having 1 parent suffering from depression themselves provides the child with a learning model influencing their daily habits. Typically, children may also try to please the parents or caretakers in an attempt to develop interactions and attract their attention. Knowing the personal and family background story of the children they care for, and being able to recognize warning signs suggestive of depression, will allow pediatric healthcare professionals to predict the outcome. Depression is a complex condition of unclear causation.24Mullen S. Major depressive disorder in children and adolescents.Ment Health Clin. 2018; 8: 275-283Crossref PubMed Google Scholar Deficiency of certain neurotransmitters have been reported to play a role in causing or contributing to depression. Serotonin has attracted the most attention, but many others including norepinephrine and dopamine have also been considered as mediators (Table II; available at www.jpeds.com).24Mullen S. Major depressive disorder in children and adolescents.Ment Health Clin. 2018; 8: 275-283Crossref PubMed Google Scholar However, the current consensus is that there is no exclusive causative element such as neurotransmitter deficiency; instead, several different contributing factors may lead to depression, including psychological or social factors, life-changing events, and biological factors such as genetics, physical illness, and chemical imbalance.24Mullen S. Major depressive disorder in children and adolescents.Ment Health Clin. 2018; 8: 275-283Crossref PubMed Google Scholar Therefore, a multidisciplinary team approach is widely adopted in the management of depression during the developmental years. Primary care pediatric providers are key figures in these teams, which should consist of psychiatrists, clinical nurse specialists/community mental health nurses, psychologists, social workers, occupational therapists, and if advisable, other disciplines including counselors, drama therapists, art therapists, advocacy workers, and care workers.25Thapar A. Collishaw S. Pine D.S. Thapar A.K. Depression in adolescence.Lancet. 2012; 379: 1056-1067Abstract Full Text Full Text PDF PubMed Scopus (954) Google Scholar,26Cheung A.H. Kozloff N. Sacks D. Pediatric depression: an evidence-based update on treatment interventions.Curr Psychiatry Rep. 2013; 15: 381Crossref PubMed Scopus (29) Google Scholar Children with depression frequently face major challenges with stigma, isolation, and discrimination.27Birmaher B. Brent D. Bernet W. Bukstein O. Walter H. Benson R.S. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.J Am Acad Child Adolesc Psychiatry. 2007; 46: 1503-1526Abstract Full Text Full Text PDF PubMed Scopus (599) Google Scholar These conditions are often complicated by difficult access to health care and education facilities. Depression can go unrecognized in adolescents if they are developing their personalities within the dynamics of the family context, struggling with independence, and facing difficult academic and career decisions.