Depression in adolescents is a serious issue. Major Depressive Disorder is diagnosed when a depressed mood or loss of interest persists for at least two weeks and causes functional impairment. Adolescence is a period of heightened vulnerability due to brain development and sensitivity to social and environmental factors. Risk factors for adolescent depression include bullying, media use, sleep problems, family history, stressful life events, and LGBTQ identity. Left untreated, depression can have long-term negative consequences including poor outcomes, recurrence of depression, and increased suicide risk. Current treatment approaches include psychotherapy such as CBT and medication like SSRIs, though medications may have side effects in teens. Future directions focus on mindfulness, acceptance, and improving emotion regulation skills. Maint

1. Adolescent Depression
Who is at risk and why?
11/16/2015
Kaja LeWinn, Sc.D
Assistant Professor of Psychiatry

2. What we are discussing today
 Little “d” depression
‒ “That movie made me so depressed”;
‒ “I’m so depressed, they ran out of my favorite potato chips”
vs.
 Major Depressive Disorder (MDD)
‒ At least 2 weeks of depressed mood or losing interest in
pleasurable activities
‒ Functional impairment in social, occupational, or educational
settings
11/16/2015Adolescent Depression: Who is at risk and why?2

3. The Burden of Depression: DALYs
11/23/2015Adolescent Depression: Who is at risk and why?3
Disability-Adjusted Life Years
(DALYs): years lost to early
death, disability, or poor health
caused by the illness1
1World Health Organization (2012)
http://www.who.int/healthinfo/global_burden
_disease/estimates/en/index2.html; Whiteford
et al., 2010, Lancet
Worldwide, mental health
disorders account for 7.4% of
disease burden2

4. DALYs for mental health disorders by age1
Adolescent Depression: Who is at risk and why?4
1Whiteford et al. 2010. The Lancet
11/16/2015

5. Adolescent Depression in the U.S.
11/23/2015Adolescent Depression: Who is at risk and why?5
National Survey on Drug Use and
Health, Mental Health Findings;
SAMHSA 2013

6. What makes
adolescence
unique?
Adolescent Depression: Who is at risk and why?6 11/16/2015

7. Adolescence as a sensitive period of development
 A developmental period marked by greater sensitivity to stimuli
 Adolescence is a sensitive period for the development of the social brain1,2
• Heightened sensitivity to social cues
• Heightened influence peers
• Important rewards and threats are in the social domain; high sensitivity to
social rejection
 Adolescence is a time of great learning, adaptation, and motivation
 But also a time of vulnerability
Presentation Title and/or Sub Brand Name Here7
1Dahl et al., 2012, Nature Neuro Rev; 2Blakemore, 2014, Annu Rev
Psychol
11/16/2015

8. Bullying
 20% report being bullied at school1
 Much higher rates among LGBTQ youth2
  risk for depression/suicidal ideation3
 Cyber bullying
• 20-40% of kids are victims4
• Females and sexual minority youth at
greater risk4
•  risk for suicidality4
Adolescent Depression: Who is at risk and why?8
1CDC, 2014, MMWR Surveillance Summaries; 2CDC, 2009, YRBS Results;
3Klomek et al., 2007, JAACAP; 4Aboujaoude et al., 2015, J Ad Health
11/16/2015

9. Media Use Among Teens
 TV exposure may increase
depressive symptoms1
 High screen time:
•  exposure to unattainable body
images, violence, normalization
of drug/alcohol use2,3
•  attention, obesity, school
problems
 AAP: <2 hours per day; screen free
zones
Adolescent Depression: Who is at risk and why?9
Kaiser Study on Media Use (Rideout et al., 2010)
1Primack et al, 2009, JAMA; 2Stice, 2001, JSCP; 3Brown et al, 2002, J
Ad Health
11/16/2015

10. Sleep
 Media use associated with later bed
times and shorter sleep duration1
 Teens need more sleep than
adults2
 25% report <6hrs of sleep3
 Many hormones released during
puberty affected by sleep4
 Disrupted sleep is often a symptom
but may also be a cause of
depression in teens4,5
 Earlier bedtimes may reduce risk of
depression6
Adolescent Depression: Who is at risk and why?10
1Cain, 2010, Sleep Medicine; 2Carskadon, 2004, Ann N Y Acad Sci;;
3Wolfson, 1998, Child Dev.; 4Dahl et al, 2002, J Ad Health; 5Roberts, 2009,
J Adol.; 6Gangwisch et al.2010, Sleep.
11/16/2015

11. Who else is at risk for developing depression?
 Teens with parents or siblings with depression1
 Teens exposed to violence and abuse1
 Teens experiencing stressful life events (divorce, death of a loved one) 1
 LGBT youth2
 Drug and alcohol users3
 Teens with other physical or mental health problems1
Adolescent Depression: Who is at risk and why?11
1Birmaher et al., 1996, JAACAP; 2Marshall et al, 2011, JAH; 3Halfors, 2005, Am
J Prev Med
11/16/2015

12. Depressed adolescents have a higher risk for…
 Poor school outcomes1
 Future, more severe depression1
 Poor relationships1
 Drug and alcohol use 1
 Suicide
• 3rd leading cause of death2
• Suicide attempts: 2x higher in female
teens in past year2
• Suicide: 4x higher in males; 77.9%2
• MDD most significant risk factor3
Adolescent Depression: Who is at risk and why?12
1Birmaher et al., 1996, JAACAP; 2CDC, 2015; 3Brent, 1993, JAACAP
11/16/2015

13. Take Home Points
 Rates of depression increase dramatically during adolescence
 Girls are at greater risk than boys
 Adolescence is a sensitive period of development with many social, physical,
and psychological changes the Social Brain
 Bullying, media use, and sleep patterns have important implications for
adolescent depression
 Some teens are at greater risk for depression because of their family history
and life experiences
 Adolescent depression has many negative effects on future outcomes
Adolescent Depression: Who is at risk and why?13 11/16/2015

14. What Does Depression
Look Like in the Brain?
11/23/2015
Olga Tymofiyeva, PhD
Department of Radiology and Biomedical Imaging

15. “It is all in your head”
11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD1

16. Brain ImagingMagnetic resonance
imaging (MRI)
• safe
• sensitive

17. 11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD3
k-spaceRadio-
Frequency
Pulses
Gradient
pulses
Received
signal
Magnetic resonance imaging
MRI image

18. Structural Functional (fMRI) Diffusion MRI
GRAY MATTER
WHITE MATTER

19. amygdala
striatum
prefrontal
cortex
The Adolescent Brain:
Still Under
Construction

20. What does
DEPRESSION
look like in the brain?
• Hyperactive amygdala
• Smaller hippocampus
• Reduced striatal
connectivity and
response to reward

21. neural
remodeling
Developmental
events and gender
Environment
(stressors, life events)
Genes
depressive
episode

22. Yes, “It is (mostly) in your head”
But it is as real as it gets
11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD8

23. PLASTICITY

24. Take Home Points
11/23/2015What Does Depression Look Like in the Brain? Olga Tymofiyeva, PhD10
• MRI is a safe and sensitive method for studying the brain
• The brain does not fully mature till about 25 years old
• Brain of depressed adolescents (e.g. reward circuit) looks different
• Both, genes and environment shape the brain and may increase risk
for depression
• Adolescence is also a window of opportunity: the brain is plastic,
adaptive and changes with environment

25. Adolescent Depression
Diagnostics, current treatment strategies and future directions
11/16/15
Eva Henje Blom M.D., Ph.D.
Department of Psychiatry and the Osher Center for Integrative Medicine

26. Diagnostics of Adolescent Depression
11/16/15

27. 27
Depression
Genes &
Biology
Context &
Stressful
events
Age & Gender
No single biomarker has been found for depression
Eva Henje Blom
We rely on self-rating and assessment from parents, teachers and clinicians

28. The DSM system is used for diagnoses of mental
disorders
and based on symptom criteria
Eva Henje Blom28
The DSM system does not take into consideration that
depression symptoms change across the life span and differ between genders

29. ADULTS TEENAGE GIRLS TEENAGE BOYS
Mood Sad, depressed Sad, depressed or irritable
Activity Inhibition Agitation
Sleep Early morning wake up Insomnia, delayed sleep phase
Appetite, weight Decreased appetite – weight loss Increased appetite - weight gain
Impulsivity Non impulsive behavior Impulsive behavior internalized:
self-harming, binge eating
Impulsive behaviour externalized:
behavioral problems, risk-taking,
substance abuse
Symptom criteria of Major Depressive Disorder (MDD)
29 Eva Henje Blom
Required symptoms
 Depressed, sad or irritable mood and/ or a loss of interest or pleasure in daily activities
 Present for most of the time for more than two weeks
 Impaired function in daily life

30. Signs to look out for in teenagers
 Insomnia & day-time tiredness
 Increased irritability
 Concentration difficulties
 Bodily symptoms: headaches, stomach aches
 Anxiety, worry, trouble relaxing
 Binge eating – eating disorders
 Self harming behavior
 Behavioral problems – risk taking
 Substance abuse
Eva Henje Blom30

31. Current treatment strategies
11/16/15

32. Eva Henje Blom32
 Deal with a crisis here and now
 Manage life
 Create a sense of safety and hope
 An alliance that can be trusted
 Help regulate emotions and sleep
 Make sense for the adolescent, transparent
In the acute situation

33. Cognitive Behavioral Therapy (CBT)
Eva Henje Blom33
By identifying and challenging negative thinking such as rumination and worrying
the world may be perceived and interpreted in more functional ways
Top-down cognitive control of emotional processes
Interpersonal Psychotherapy (IPP)
Dialectic Behavioral Therapy (DBT)
Focuses on increasing social support and
managing relationships that contribute to and maintain emotional stress
Learning behavior of both acceptance and change
Acceptance skills = being mindful and increase tolerance to distress
Change-oriented skills = emotion regulation and interpersonal skills
Evidence-based psychological treatments

34. Antidepressant drugs
Eva Henje Blom34
Selective Serotonin Reuptake Inhibitors (SSRIs)
are the most commonly used antidepressants for
teenagers
14.2% of US teenagers with mood disorders are being
prescribed SSRIs Ref: Merikangas et al. Medication use in US youth with
mental disorders. JAMA pediatrics. 2013
Fluoxetine (Prozac) is the only SSRI approved for
teenagers
For teatment resistant depression other drugs are also
being used
Less effective in teenagers compared to adults
It has not been proven that
depression is caused by deficiency
of any specific neurotransmitter

35. Side effects of SSRIs in adolescents
Eva Henje Blom35
Very common:
 sleep disturbances
 diarrhea, nausea
 headache
 tiredness
Common:
 sexual dysfunction
 changes in appetite and weight
 anxiety, restlessness
 concentration difficulties
Specific to adolescents:
 increased aggressive and violent behavior
 increased suicidal ideation:
serious warning issued by FDA up through age 24
Important:
 emotional blunting and indifference
 symptomatic worsening during the first weeks of treatment
 withdrawal symptoms at discontinuation

36. Future Directions
11/16/15

37. Behavioral Activation (BA)
11/23/2015Eva Henje Blom37
Targets behaviors that might maintain or worsen the depression
to create positive change
Helps people understand environmental sources of their depression

38. Shift away from rumination and worrying
by practicing present-moment sensory and interoceptive awareness
Help recognizing emotions in the body and improve attention
Eva Henje Blom38
Mindfulness-based skills
Mindfulness techniques are also applied in school based preventions
such as Socio Emotional Learning (SEL)

39. Find out what you value the most in your life
Challenge patterns of emotional avoidance
Eva Henje Blom39
Acceptance Commitment Therapy (ACT)

40. Training for Awareness Resilience and Action
TARA
TARA is developed at UCSF and based on
current neuro-scientific findings of adolescent
depression and brain development
Targets primarily amygdala hyper-reactivity and improve
emotion regulation and attention skills through bodily practices
such as breathing and slow movement
TARA is currently being tested with behavioral and
neuroimaging outcomes as part of the BrainChange Study
11/23/2015Eva Henje Blom40

41. Connection & Trust
Eva Henje Blom41
 Cultural humility
 Empathic listening
 Authenticity
 Seek support
 Give the rationale
Maintain connection
even when being dismissed