​Kembara Xtra - Medicine - Adolescent Depression

​Kembara Xtra - Medicine - Adolescent Depression 
Introduction 

Major depressive disorder (MDD), disruptive mood dysregulation disorder (DMDD), persistent depressive disorder (PDD), premenstrual dysphoric disorder, substance or medication-induced depressive disorder, and other nonspecific depression are all included in the DSM-5 list of depressive disorders. This chapter focuses on major depressive disorder (MDD) in the context of the adolescent patient.
Major depressive disorder (MDD) is a major mood illness that is characterized by feelings of sorrow and/or irritability along with impairment of functioning, aberrant psychological development, and a loss of self-worth, energy, and interest in things that are generally enjoyable.
DMDD is defined by having violent, recurring outbursts combined with persistent irritability and rage. These symptoms are often present together.
PDD is characterized by a depressed mood for most days lasting at least one year in a child or adolescent. Adolescents with depression are likely to suffer broad functional impairment across social, academic, family, and occupational domains, in addition to a high incidence of relapse and a high risk for substance abuse and other psychiatric comorbidity. PDD is characterized by a depressed mood for most days lasting at least one year.

Epidemiology (Prevalence and Incidence) 

Incidence
The cumulative risk of developing depression during adolescence ranges from 5% to 20% of the population.
Prevalence

 Major depressive disorder: 6–12% of teenagers; twice as prevalent in females. Disruptive mood dysregulation disorder: 2–5%; more prominent in boys.

Causes and effects: etiology and pathophysiology 
Uncertainty; low levels of neurotransmitters (serotonin, norepinephrine); impaired functioning of the dopamine system also contributes to the problem.

It is possible for external variables to have an independent effect on neurotransmitters.
Alterations in hormone levels that occur throughout puberty

Genetics Children of depressed parents have three to four times the risk of developing depression compared to children of parents without a mood disorder. Family studies suggest that anxiety in childhood is often a precursor to depression in adolescents.


Previous episodes of depression, a history of sleeplessness, anxiety disorders, attention deficit hyperactivity disorder (ADHD), body dysmorphic disorder, chronic childhood illness, and/or learning difficulties are all considered to be risk factors for developing depression.
a greater amount of time spent in front of electronic media; being female; being subjected to general stresses such as unfavorable life events, difficulties with peers, the death of a loved one; academic challenges; abuse; chronic illness; tobacco abuse; and a low socioeconomic position; being classified as a member of the LGBTQ community; and


Prevention 
There is some evidence to suggest that properly treating depression in a mother can have a positive impact on the mental health of her children and adolescents.

 The United States Preventive Services Task Force (USPSTF) advises the screening of adolescents (12 to 18 years of age) for major depressive disorder (MDD) when protocols are in place to assure an accurate diagnosis, appropriate treatment, and follow-up.

Conditions That Often Occur Together 
Generalized anxiety disorder is related with substance misuse, eating problems, and behavioral disorders. Twenty percent of people satisfy the criteria for generalized anxiety disorder.


DIAGNOSIS HISTORY
It is possible for adolescents to appear with somatic problems that cannot be explained by medical conditions, such as weariness, irritation, or headache.
According to the criteria of the DSM-5, at least five of the following symptoms must have been present within the same two-week period and show a shift from the individual's previous functioning: At least one of the symptoms is a low mood, which may also be accompanied by a loss of interest or pleasure:

- Criterion A: Depressed mood for the majority of the day, practically every day, as reported by the individual experiencing it or as observed by others (feelings of melancholy, emptiness, or hopelessness; in youngsters, this can manifest as irritability).
Significant weight loss when not dieting or significant weight gain (>5% body weight in 1 month) symptoms include: a markedly lessened interest or pleasure in any and all activities for the majority of the day, practically every day
○ Insomnia or hypersomnia
 Agitation or retardation of psychomotor processes virtually every day
 Decreased capacity to focus or concentrate, or indecisiveness, nearly every day emotions of worthlessness or excessive or inappropriate emotions of guilt nearly every day Fatigue or loss of energy nearly every day repeated thoughts of death, repeated suicidal ideation, or try to take one's own life nearly every day Feelings of worthlessness or excessive or inappropriate feelings of guilt nearly every day 
- The second criteria. The symptoms cause clinically substantial distress or impairment in social, occupational, or other important areas of functioning. Symptoms create anguish or impairment in crucial areas of functioning.
– The C-criterion. This episode cannot be attributed to the impact of any substances or any other medical issues.
- Criteria number four. There is no evidence that a schizoaffective, schizophreniform, or delusional condition is a more accurate explanation for episode.
- The Ethical Standard. There has never been even a single incidence of mania or hypomania.

The Patient's Clinical Examination 
It is possible for individuals to have psychomotor impairment or agitation. Clinicians need to carefully examine patients for symptoms of self-injury (such wrist lacerations) or abuse.

Differential Diagnosis Substance-induced mood disorder Bipolar disorder Adjustment disorder with depressed mood Mood disorder secondary to a medical condition (thyroid, anemia, vitamin deficiency, diabetes) Mood disorder secondary to organic CNS diseases Malignancy Infectious mononucleosis or other viral diseases Attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), eating disorders, and anxiety disorders Sleep disorder Sadness

Results From the Laboratory 

Initial tests (laboratory and imaging) may be utilized to eliminate other potential diagnosis (for example, complete blood count, thyroid stimulating hormone, glucose, vitamin B12, folate, monospot, and urine drug).

Additional Examinations, as well as Other Important Factors
There isn't one that has adequate sensitivity and specificity for diagnosis.

Diagnostic Methods and Other Procedures
Standardized tests are helpful as screening tools and to evaluate response to treatment, but they should not be used as the only basis for diagnosis. Depression is often diagnosed after a formal interview, with supporting information from caregivers and teachers.
– Beck Depression Inventory II (BDI-II): between the ages of 13 and 18 years old 
- Center for Epidemiological Studies Children's Depression Inventory 2 (CDI 2): ages 7 to 17 years old Patient Health Questionnaire-9 (PHQ-9): ages 13 to 17 years, with an optimal cut point of 11 or above (instead of 10 used for adults) Depression Scale for Children (CES-DC): ages 6 to 17 years Depression Scale for Children (CES-DC): ages 6 to 17 years
The United States Preventive Services Task Force (USPSTF) suggests that teenagers between the ages of 12 and 18 be screened for major depressive disorder (MDD), but it states that the evidence that is now available is insufficient to evaluate the benefits and risks of screening children aged 11 years or younger.

The evaluation of adolescents who test positive for depression using standardized screening and interviewing procedures should include an assessment of the potential for the adolescent to cause damage to themselves or to others.


In moderate cases, active support and monitoring using short validated scales should be employed for assessment and management for a period of six to eight weeks.
If active support and monitoring do not alleviate symptoms, then you may want to consider psychotherapy and/or medication as additional treatment options.

 Psychoeducation, supportive management, and engagement of both the family and the school should all be components of the treatment.

The initial management should consist of treatment planning and making sure that both the patient and their family are at ease with the proposed course of action.

According to the findings of a Cochrane analysis, there was no significant difference between the remission rates of adolescents who were treated with cognitive-behavioral therapy (CBT) as opposed to medication or combination therapy immediately postintervention.
According to the findings of a multitreatment meta-analysis, the combination of fluoxetine and cognitive behavioral therapy (CBT) had a higher efficacy than monotherapies, although other selective serotonin reuptake inhibitors (SSRIs), such as sertraline and escitalopram, were better tolerated.


The First Line Of Defense Is Medication
Fluoxetine: for the treatment of depression in patients older than 8 years. Starting dose is 10 mg per day, with an effective dose ranging from 10 to 60 mg per day. The SSRI that has been studied the most, which also happens to be the one with the most positive data about its efficiency and safety, has the longest half-life of all the SSRIs and is not often associated with withdrawal symptoms either between doses or when it is stopped.

 Escitalopram is recommended for patients older than 12 years who are depressed. Initial dose of 5 mg per day, with an effective dose ranging from 10 to 20 mg per day

 Citalopram is recommended for patients older than 12 years who are depressed. The recommended starting dose is 10 mg per day, with an effective dose ranging from 10 to 40 mg per day.

Sertraline is prescribed to treat depression in patients older than 12 years. Initial dose of 25 mg per day, with an effective dose ranging from 50 to 200 mg per day

It is possible to titrate the dose once every one to two weeks if there are no major adverse effects (such as headaches, GI discomfort, sleeplessness, agitation, behavior activation, or thoughts of suicide). (6)[A] ALERT SSRI black box warning to watch for worsening of disease, changes in behavior, and suicidal thoughts and feelings
Because of this elevated risk for suicidality, it is essential to conduct close monitoring for suicidality as well as other side effects after commencing pharmacotherapy in a child or teenager. It is recommended that you follow up in two weeks.
It is possible that adolescents are at a larger risk for withdrawal symptoms from SSRIs than adults are due to their rates of accelerated drug metabolism. If withdrawal symptoms are present, it is possible that twice-daily dose may be considered.

When stopping treatment with any SSRI other than fluoxetine, a gradual reduction in dosage is recommended.

Considerations Relating to Children
It has not been demonstrated that tricyclic antidepressants, also known as TCAs, are beneficial in treating depression in teenagers; therefore, they should not be used.

● Paroxetine (SSRI): Avoid using this drug because of its short half-life, the withdrawal symptoms connected with it, and the higher risk it poses for suicidal ideation.


Issues for Referral 
After a period of one year, patients who received care through collaborative care interventions for mental health and primary care saw a better improvement in their depressed symptoms.

If the patient's depression is severe, treatment-resistant, or recurrent, or if they have concomitant conditions, a referral to a child psychiatrist is recommended.

Alternative Medication St. John's wort, acupuncture, S-adenosylmethionine, and 5-hydroxytryptophan have not been proved to have an effect in teenage depression or have insufficient data to support their usage. Physical activity and light therapy may have a slight to moderate effect.

Admission
It is possible that one-on-one supervision is required for someone who is seriously depressed, psychotic, suicidal, or homicidal.

Ongoing Medical Attention 
After the symptoms associated with depression have subsided, it is recommended that antidepressant treatment be maintained for another six to twelve months at the full therapeutic dose.
Once the symptoms have subsided, continue monitoring on a monthly basis for the next six months, then on a more consistent basis over the next 18 months.


Continued Patient Observation and Monitoring
SSRI drugs come with a "black box" warning that instructs patients to keep an eye out for deteriorating conditions, changes in behavior, and thoughts of suicide.

 It is recommended that a methodical and consistent tracking of treatment goals and outcomes be carried out. This tracking should include an assessment of depression symptoms and functioning in relation to family, school, and peer environments.

If there is no improvement after 6 to 8 weeks of treatment, the diagnosis and initial treatment should be reevaluated. The goal of treatment should be the prolonged remission of symptoms and the restoration of full function.
Patients and their family members should be educated about the causes, symptoms, course, and treatments of depression, as well as the dangers associated with therapies and the risks associated with not receiving treatment.

The prognosis is that between 60 and 90 percent of bouts will clear up within one year, and between 50 and 70 percent of remissions will lead to new episodes of depression within the next five years.
Depression throughout adolescence is a good predictor of mental health disorders in adult life, as well as psychosocial challenges and health problems.


Complications: mania, violence, or a lack of improvement in symptoms brought on by treatment; school failure or refusal; one-third of adolescents who have suicidal ideation go on to attempt suicide.