Lecture 21 - Childhood Depression

Question 1

Epidemology

Answer 1

Prevalence 4%-8%
Rare in childhood, common in adolescence
•Rates are 2x higher in females relative male, from adolescence onwards (internalizing problems)
•No sex difference in depression prior to adolescence (externalizing problems)
•Age of onset: Adult studies: 15 -19 years
Child studies: 13 -15 years

Question 2

What is unique about mood disorders in children and adolescents, relative to adults?

Answer 2

1. Irritabilityinstead of euphoric/depressed mood (applies to both MD and BD) - Irritability is common to many other disorders (ADHD, ODD)
2. BD before age 12 (broadly defined pediatric BD) includes the unusual presentation of chronic irritability andrapid mood cycling without discrete episodes of mania
   •NOW, this is called disruptive mood dysregulation disorder
   •This presentation is highly comorbid with ADHD
3. Somatic symptoms are common in childhood depression (stomach aches, etc).

Question 3

Etiology

Answer 3

• BD in parent= risk for MD and BD
• MD in parent= risk for MD only
• Genetics: both heritability (40%-60%) and unique (non-shared) environmental experience important
Multiple family and environmental risk factors associated with having a parent with depression, BD, and any psychopathology in parents
• Family instability (marital problems, violence, less social support)
• High stress and abuse/neglect
• Less effective parenting
• Insecure attachment

Question 4

Biological Risks

Answer 4

• Structural/functional changes brain function: a number of studies indicate that infants (3-14 months) of depressed mothers show greater right than left EEG asymmetry (less neuronal activation in the left hemisphere relative to the right hemisphere) than infants of mothers with no depression (Left hypofrontality)
• Stress and changes in the hypothalamic-pituitary-adrenal axis (HPA).

Question 5

Reading 7

Answer 5

Mean cortisol levels, averaged over two days, were higher in the offspring of BD (bipolar disorder) parents than the offspring of control parents, 16 years of age (Ellenbogenet al, 2006, 2010)

Question 6

Why do the offspring of parents with bipolar disorder have high cortisol levels? (reading 7)

Answer 6

3 possible reasons

(1) Early environment: They are exposed to disorganized and inconsistent parenting, and stress in the home during childhood (Ellenbogen& Hodgins, 2009)
(2) They are exposed to more stress in adolescence and young adulthood (Ostiguyet al, 2009)
(3) More biologically sensitive to stress (Ostiguyet al, 2011)

The OBD exposed to high stress exhibited increased cortisol levels than the OBD who were exposed to lower levels of stress

• **This relationship was much stronger in the OBD than controls, indicating that they are more sensitive to naturalistic stress
• ** effect evident for both chronic and episodic stress

Question 7

Effects of having depressed mother

Answer 7

• Depressed mothers express less positive affect(happiness, interest) and more negative affect(sadness, anger) with children, in terms of facial expression and speech
• Infantsof depressed mothers likewise express more negative affect and less positive affect, and lower activity levels (genetic or modelling?)

Higher prevalence of insecure attachment
• Parenting styles that unresponsive, insensitive, lacking warmth (at the extreme, neglectful) but also..
• intrusive (at the extreme, harsh)
• Abusive parenting

Question 8

Reading 8 - Hammen

Answer 8

STRESS
• Stress is seen as a precipitant (trigger an episode) and as a risk factor for depression
• Diathesis-stress model has focused on three aspects of “vulnerability”
• Cognitive risk factors
• Genetic and/or HPA/biological stress sensitivity
• Social/interpersonal problems, that limit one’s ability to cope with adversity
• Depression is associated with stress in close relationships, and girls are particularly at risk for this type of stress
• Found that girls are more “stress-sensitive”, in that they are more likely to become depressed following interpersonal stress than boys

Question 9

Stress - generation hypothesis

Answer 9

Reading 8 - Hammen
• We now know that it is dependent life events, and not independent ones, that are linked to depression
• Dependent life event refers to event where the person has some role in its occurrence, like conflicts with family, relationship probs. Independent events are events in which the person has no control, such as earthquakes or a death in the family
• Rudolph, Hammen, et al (2000)found that depression was associated with significantly more interpersonal dependent stressors (family and peer probs), but not non-interpersonal stressors like academic problem in clinic-referred adolescents.
• POINT: DEPRESSED YOUTH ‘GENERATE’ STRESS IN THEIR ENVIRONMENT

Question 10

3 important concepts central to the transactional model

Answer 10

1. Most influences are bidirectional
2. Risk and etiology changes across development
3. There are different pathways to depression

Question 11

The treatment of adolescents with depression study (TADS)

Answer 11

• 439 adolescents, aged 12-17, diagnosed with major depression
• 4 treatments: placebo, fluoxetine, CBT, and combination therapy

RESULTS:
• All three active treatments effective at 36 weeks
• Fluoxetine and combination therapy have a faster therapeutic effect
• CBT reduced treatment-emergent suicidal events
• Therefore, combination therapy appears superior to monotherapy

Question 12

Treatments

Answer 12

• Fluoxetine. TCAs are not effective (only drug that’s actually approved)
  • Cognitive-behavioral therapy (behavioural activation - do things that make you happy, cognitive restructuring, problem solving)
  • Interpersonal therapy (IPT)
  • All these treatments are roughly equally efficacious