Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Adolescent Depression and Suicide: Rising Problems Christopher H. Hodgman & Elizabeth R. McAnarney To cite this article: Christopher H. Hodgman & Elizabeth R. McAnarney (1992) Adolescent Depression and Suicide: Rising Problems, Hospital Practice, 27:4, 73-96, DOI: 10.1080/21548331.1992.11705400 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705400
Published online: 17 May 2016.
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Date: 03 July 2016, At: 05:13
Adolescent Depression and Suicide: Rising Problems CHRISTOPHER H. HODGMAN
and ELIZABETH R. McANARNEY
UniversltyojRochester
Downloaded by [Monash University Library] at 05:13 03 July 2016
In adolescents, as in adults, most depressive persons are not suicidal, and many suicidal persons are not depressed. However, accurate diagnosis and treatment of depression in adolescent patients is essential to suicide prevention. Unfortunately, depression and suicidality remain widely undiagnosed and untreated in the adolescent population.
OVer the past 40 years, the rate of adolescent suicide in the United States has increased dramatically. Suicide is now the third leading cause of death among American adolescents, with rates roughly three times as high today as in 1950 (Figure 1). Diagnoses of adolescent depression have also been on the rise. Although some have questioned whether this increase indicates an actual rise in the prevalence of adolescent depression or simply reflects improved diagnostic methodologies, the fact remains that adolescent depression is widespread. By one estimate, mild to severe depression affects 36.3% of adolescents. Self-reported depressive symptoms for 14- to 15-year-olds run as high as 41.7% for boys and 4 7. 7% for girls. While some relationship between depression and suicide in general would seem obvious, it is by no means straightforward. As in adults, most depressive adolescents are not suicidal, and many suicidal adolescents are not depressed. However, depression is known to be a primary risk factor for suicide. Thus, accurate diagnosis and treatment of depression in adolescent patients is essential to suicide prevention in this population. Unfortunately, depression and suicidality have been, and remain, widely undiagnosed and untreat-
Dr. Hodgman is Associate Professor, Department of Psychiatry and Department of Pediatrics, and Dr. McAnarney is Professor and Associate Chair (Academic Affairs), Department of Pediatrics, University of Rochester School of Medicine. Dr. Hodgman is also Director, Division of Child and Adolescent Psychiatry, and Dr. McAnarney is Chief, Division of Adolescent Medicine, Strong Memorial Hospital, Rochester, N.Y.
ed in the adolescent population, as in the population at large. Indeed, a clear majority of cases of adolescent depression are untreated in the United States. On a more positive note, significant advances have been made over the past decade in the conceptualization, diagnosis, and treatment of depression and suicidality. Pediatric depression in general is no longer viewed as a problem distinctly different from adult depression, to be managed by mental health professionals in nonmedical settings. Adolescent depression and suicidality are now seen in the context of a lifelong continuum of affective disorders, defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM-III-R), and falling within the purview of general psychiatry, which now includes child psychiatry as a medical subspecialty. This reconceptualization of adolescent depression and suicidality has resulted largely from the pharmacologic revolution in psychiatry and a decade of research into the biology of depression and suicide. Although much remains to be learned, it is now known that at least some, if not all, forms of depression and suicidality are characterized by common biochemical features, such as low levels of biogenic amines (e.g., norepinephrine and serotonin), which are believed to be essential for transmission of positive-affect stimuli in the central nervous system. FUrthermore, several types of depression have been shown to respond to treatment with the same range of antidepressants, when administered in conjunction with psychological support. These findings should not be interpreted to mean, however, that all depression and suicidality Hospital Practice April 15, 1992
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are caused exclusively by biologic and genetic factors or share a single etiologic agent. Depression and suicidality in adolescents, as in adults, may be triggered by a variety of psychological and environmental as well as biologic factors, including personalloss, anniversaries of emotional trauma, season of the year, viral illness, and chemicals. This multifactorial view of depression and suicidality does not invalidate the hypothesis that these conditions may share a common biochemical pathway. Studies have suggested, for example, that availability of biogenic amines in the central nervous system can be influenced by
thoughts, just as thoughts and emotions can be influenced by neurochemicals. The statement that psychological factors may trigger depression is also consistent with the hypothesis that genetics may play a role in all forms of depression, although this hypothesis has yet to be confirmed empirically. A variety of studies have shown that genetic abnormalities underlie at least some forms of depressive illness, such as bipolar disorders. Electrophoretic evaluation of DNA fragments has revealed defects at specific chromosomal locations in some depressive patients. Expression of these abnormal-
Figure 1. According to a 1991 study by Charles E. Irwin, Jr., and colleagues at the University of California, San Francisco, motor vehicle injuries were by far the most frequent cause of death in older adolescents (aged 15 to 19 years) in the United States from 1950 to 1986. In the same period, however, the incidence of suicide increased 200%, from less than 3/100,000 to about 10/1 00,000-a rise that enabled suicide to surpass cancer, cardiovascular disease, and homicide and become the third leading cause of death in older adolescents.
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ities is incomplete, however, pointing to the role of psychological and environmental factors in determining if a genetic defect manifests as depression. Genetic factors may also underlie suicidality, according to some research. Studies of Old Order Amish families in the United States have revealed in some families an inherited tendency to depression, in still others a tendency to suicide, and in others a tendency to both depression and suicide (Figure 2). Other studies indicate that children adopted from families with a history of suicide into families with no such history are more likely to kill themselves than are children adopted from families with no history of suicide. It is possible that the genetic inheritance in some of these patients is a tendency to have inadequate levels of serotonin or norepinephrine in the central nervous system, predisposing them to dysphoria, impulsivity, or affective responses to situations. Confirmation of this hypothesis awaits further genetic studies and a more complete conceptualization of the organic etiology of depression and suicidality. Understanding of adolescent depression and suicide has been advanced in recent years not only by research into the biology of these conditions but by a variety ofclinical, epidemiologic. and social scientific studies as well. It is nowknown,forexample, thatsignificant comorbidity of depression and other medical and psychiatric conditions exists, and that depression tends to go undiagnosed and untreated in most of these cases. Psychiatric conditions often accompanied by depression include anxiety disorders, eating disorders, conduct disorders, borderline states, and substance abuse (which, in the case of alcohol, may function as
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Figure 2. In a retrospective study of Pennsylvania's Amish, Janice A. Egeland and James N. Sussex of the University of Miami found presumptive evidence of genetic factors in suicide and affective disorders such as depression. The evidence included this six-generation pedigree, which contains six cases of ascertained suicide, two of suspect-
self-medication for depression by temporarily raising serotonin levels in the central nervous system). Depression also accompanies serious physical illness in some, but surprisingly not the majority, of adolescent patients. Again, depression is rarely co-diagnosed and treated in these cases, although our experience at the University of Rochester Medical Center has shown that antidepressant medications can be administered successfully to such
ed suicide, and 19 of bipolar, unipolar, or other affective disorders (diagnosed according to criteria used in research involving deceased subjects). Other psychiatric illnesses, some undiagnosed, were also noted. An affective disorder was diagnosed in five ascertained and one suspected suicide. (Adapted from JAMA 254:915, 1985)
patients in conjunction with the medications prescribed to treat the primary physical illness. FUrther studies have contributed to the articulation of risk factors, both internal and external, for adolescent suicide. Depression and other psychiatric morbidity; stressful life events, such as parental divorce or a death in the family; an unstable, violent home life; a family history of suicide, drug and alcohol abuse, and psychiatric illness; homosexuality; and personality
characteristics such as self-derogation, intropunitiveness, and poor problem-solving skills have all been associated with an increased risk of suicide in adolescent patients. Other studies have investigated societal factors underlying the increased prevalence of adolescent suicide in recent decades. It has been suggested, for example, that the breakdown of the family and traditional beliefs and the increase in geographic transiency have contributed to Hospital Practice April 15. 1992
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the erosion of social and psychological support systems that formerly buffered adolescents against life stresses, such as economic hardship and personal loss, thus protecting against suicidality. Concomitantly with advances in research of adolescent depression and suicide, physicians have gained much clinical experience over the past decade in the diagnosis and treatment of these conditions. Given the abundance of current information and experience relevant to adolescent depression and suicide, primary care practitioners-in particular, pediatricians-need no longer view these conditions as lying entirely outside the scope of their medical practice. Indeed, it is critical that family physicians, pediatricians, and other primary care practitioners become aware of the symptoms, diagnostic methodologies, and treatment approaches to adolescent depression and suicidality and take an active role in their management in consultation with psychiatric specialists. Accordingly, this article reviews current knowledge about the epidemiology, etiology, symptomatology, diagnosis, and treatment of depression and suicidality in adolescent patients. Statistics tracking the incidence of adolescent suicide over the years, although clear in showing an upward curve, are complicated by a variety of factors, beginning with inconsistency in the very definition of adolescence. One easy definition is that it represents the second decade of life, from 10 to 19 years of age~ In most statistical analyses, adolescents are divided into two subcategories: early or young adolescents, aged 10 to 14 years, and mid-to-late or older adoles76
Hospital Practice Aprlll5, 1992
cents, aged 15 to 19 years. One national data-gathering organization includes 20- to 24-yearolds in the older adolescent category. Such inconsistencies make comparisons of data difficult. For the purposes of this discussion, we will define adolescents as youths in the second decade of life. Further complicating the mortality figures for adolescent suicide is that a number of suicides are recorded as accidental deaths, which are the leading cause of death among adolescents by a wide margin. According to the National Center for Health Statistics, motor vehicle and other accidents accounted foradeathrateof66.6/100,000 in male adolescents 15 to 19 years of age, and 18.5 for the 10to 14-year-olds in 1987. For females of the same age groups in that year, the numbers were 25.1 and 7.0, respectively. Suicideconsistently a leading cause of adolescent deaths in recent years-accounted for 16.2 and 2.3 deaths per 100,000 in the older and younger adolescents, respectively. For females, the comparablenumberswereabout one fourth those for males-altogether a total of 2,152 deaths. (Homicide and suicide rates for adolescents tend to be very close. In 1987, for example, the homicide rate for older adolescent males was 15.3/100,000. Until 1985, homicide was the third leading cause of death in adolescents, but it is now exceeded by suicide in this age group. Of the 51.0/100,000 male and 22.2/100,000 female motor vehicle deaths among older adolescents in 1987, some were no doubt "successful" suicides masquerading as accidents. The exact number of suicides hidden in accident reports is, of course, impossible to determine. But it is known that almost as many
adolescent suicides are caused by impulsiveness as by depression-a fight with a boyfriend ending in an intentional car crash, for example. It has been demonstrated that more than half of adolescent suicidal behavior occurs after less than 30 minutes' deliberation, and a quarter with less than 15 minutes' deliberation. It can be concluded, therefore, that impulsive suicides make up some proportion of fatalities listed as accidents each year and that actual suicide rates are somewhat higher than reported. Statistics reveal other important demographic features of adolescent suicide relevant to its diagnosis. Adolescent boys are roughly four to five times as likely to commit suicide as are adolescent girls, although adolescent girls are much more likely to engage in nonlethal suicidal behaviors. There are roughly 50 to 200 times as many "unsuccessful" suicide attempts as completed suicides among adolescents annually, which indicates that suicide rates are a woefully inadequate measure of the prevalence of suicidality in the adolescent population. Firearms and explosives are the leading instruments of self-inflicted death among adolescent boys and girls alike, with handguns accountable for more than 80% of adolescent suicides. The prevalence of adolescent depression is difficult to determine accurately, in part because different diagnostic methodologies have yielded widely varying results. Stuart Kaplan and colleagues at State University of New York, Stony Brook, have estimated that from 13% to 28% of adolescents may be mildly depressed, 7% moderately depressed, and 1% to 3% severely depressed. Other investigators (continues)
ADOLESCENTS
(continued)
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have published comparable findings. with estimates of major depression running as high as 9% for adolescent girls and 4% for adolescent boys. Research indicates that the reported incidence of adolescent depression and suicidality increases significantly when symptoms are vigorously sought. In a study that our group conducted at a general medical clinic for adolescents, it was found that when all adolescents attending the clinic for any reason were asked eight standard questions about depression and suicidality, diagnosis of these conditions doubled (Table 1). When the questioning was discontinued, rates of diagnosis returned to their previous levels. Admittedly, however, self-reported symptoms of depression and suicidaltty in teenagers must be viewed with some skepticism, given a proclivity among adolescents to self-dramatize. Nevertheless, we feel that the findings of this study reflect a general tendency among physicians to overlook symptoms of depressive illness and suicidality in adolescent patients. Our view is supported by a repeatedly demonstrated clinical fact: Questions about depression and suicide are rarely asked of patients of any age as part of routine medical history taking. Even when relevant questions are asked, SYmptoms of depression and suicidality are rarely considered exhaustively. This accounts, in part, for the widespread underdiagnosis of depression and suicidality in adolescent patients. Efforts to determine prevalence of adolescent depression are further complicated by depression being both an illness
and an appropriate response to major loss-an abnormal syndrome and a normal behaviorin which many of the same features may overlap. Furthermore, depression may present in adolescents as a normal response to the intense developmental stresses that characterize that phase of life. Differences between the normal response of depression and the abnormal syndrome of depression may be subtle; the pathology may be less pronounced and of shorter duration than the normal response, for example. But certain psychological features do distinguish the two: Loss of selfesteem and, in severe cases, loss of reality testing characterize the syndrome, but not the normal behavior of depression. It should be noted that both forms of depression in adolescents are underdiagnosed. Even when physicians look for depression in adolescent patients, a variety of factors can conspire to make an accurate diagnosis difficult. First, there is the problem of shifting nomen-
clature. Physicians trained before the pharmacologic revolution in psychiatry are confronted today by DSM-III-R, which has rendered obsolete many of the old familiar categories of depression, offering a nomenclature reflecting advanced understanding of its etiology. Previously, depression was viewed as either neurotic or psychotic, reactive or endogenous, primary or secondary. The discovery that patients with all of these types of depression responded to the same range of antidepressant medications called those dichotomies into question and prompted a shift in the DSM-III and DSM-III-R to primarily de. scriptive diagnoses for depression (Table 2). While this change in nomenclature may be viewed on the whole as an improvement. it nevertheless has limitations. For example, only those types of depression for which the organic etiology has been clearly demonstrated (e.g., the use of antihy(conttnues)
Table 1. A Mood Survey Used by the Authors The following questions will help us learn how you are feeling about yourself. Please note that completing this questionnaire is voluntary. For confidentiality purposes, your name will not be needed on this form. Instructions: Please circle the number 1, 2, or 3, depending on how much the question applied to you. During the past year, how often have you been bothered or troubled by: Not at All
Somewhat
Much
1
2
3
Having trouble going to sleep or staying asleep
2
3
Feeling unhappy, sad, or depressed
2
3
Feeling too tired to do things
Feeling hopeless about the future
1
2
3
Feeling nervous or tense
1
2
3
Worrying too much about things
2
3
Feeling that life isn't worth living
2
3
2
3
Feeling like hurting myself
1
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(continued)
pertensive medications such as propranolol or reserpine) are diagnosed in DSM-111-R as "organic mood disorder, depressed." However, as has been stated, it is likely that all depression has an organic component, whether the initial cause of the depression is biologic, psychological, or a combination of the two. Etiologic, and therefore diagnostic, uncertainties will persist in this area until a complete biologic conceptualization of depression is achieved. Diagnostic ambiguities such as these pose a major challenge
to the psychiatric specialist charged with fine-tuning a diagnosis ofdepression in an adolescent patient. But the pediatrician or other primary care physician faces an equal challenge in making an initial, general diagnosis of depression in such a patient. In this preliminary stage of evaluation, the practitioner's key diagnostic tool is the medical history. Primary care physicians must become familiar with the different ways depression presents in younger and older adolescents and learn to ask the right questions of adolescents of different ages. For very young patients, of course, much of the
Table 2. Current Depressive Syndromes in Adolescence Classification
Symptomatology, Course
Major depressive episode (unipolar)
Full depressive picture without episodes of mania and lasting months if untreated
Family history of depression and alcoholism common
Bipolar disorder, depressed
Full depressive picture after previous episodes of mania; cycles of variable duration
Family history of bipolar disorder, alcoholism very common
Cyclothymia, depressed
Milder, briefer form of bipolar disorder
Often misdiagnosed as character pathology
Organic mood disorder (depressed)
Full depressive picture following exposure to agents or pathogens (hallucinogens, viruses, endocrine disorders)
Removal/treatment of a predisposing condition may cure, or depression may take same course as major episodes
Dysthymia ("neurotic depression")
Chronic (at least one year in adolescents), mild, with secondary disturbances. Insidious onset; predisrosing constitutiona factors
Although milder in degree, secondary disturbances and impulsiveness pose distinct suicidal risk
Adjustment disorder with depressed mood
Stress is identifiable and its alleviation should end the disorder.
Often misapplied when removal of untreated adverse circumstances alone does not terminate depression
Bereavement
Full biologic signs of depression may occur, but usually self-esteem and reality testing are retained.
May last a year or more. Patterns more variable than usually accepted.
Adapted from DSM-111-R
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Additional Features or Comments
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medical history will be provided by parents. If a parent's assessment contradicts that of the child's, the child's view should take precedence, as a parent may tend to minimize a child's distress. The fact that depression presents differently in adolescents of different ages points to the limitations of relying strictly on DSM-III-R criteria for diagnosis of adolescent depression. While these criteria are essential to diagnosis, they may miss adolescents who are too young to verbalize, or even to identify, certain classic symptoms of depression-such as dysphoric moodin themselves. Thus; it is useful to supplementDSM-III-R cii.teria with a developmental approach to diagnosis that recognizes stage-specific symptoms of depression in adolescents of different ages and "depressive equivalents"-a phrase coined by Irving Weiner at the University of South Florida-in young adolescents who lack some of the classic presentations of depression. The developmental approach to the diagnosis of adolescent depression takes into account basic biologic, psychological, and cognitive differences that distinguish younger adolescents from older ones. Early adolescence is a stage characterized by rapid physical growth and "concrete operational thinking"-a cognitive style focused on the here-and-now. Mid-to-late adolescents have experienced most of their physical growth and move into "formal operational thinking"-a cognitive style that allows them to think abstractly, to reflect on their feelings and the feelings of others, and to think about the future. These differences between early and mid-tolate adolescents are reflected in the ways depression presents
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and is or is not articulated by those patients. In early adolescence, a primary symptom of depression is concentration difficulty, as it is in depressed patients of all ages. A diagnosis of depression should be seriously considered for a young person who has been doing well in school and suddenly shows a sharp decline in academic performance. This is a useful indicator of depression because quantitative documentation is available in the form of school records, which may help to pinpoint the onset of depression in a young patient. Early adolescent depression is also suggested by persistent boredom and restlessness. This is not the kind of periodic boredom and restlessness that affects most early adolescents from time to time but an unabated disquiet that immobilizes the adolescent and is not relieved by efforts of parents or teachers. Fatigue and preoccupation with somatic symptoms-bellyaches, headaches, backaches, joint aches-are also common symptoms of early adolescent depression. Although some preoccupation with the body is normal for youngsters at this stage, persistent somatic complaints are not. These complaints tend to be very generalized but are often quite debilitating, causing an adolescent to miss school and make repeated visits to the doctor's office or emergency room for the srune symptoms. Nothing the physician or parent does seems to provide relief. Another of the depressive equivalents in early adolescence is acting-out behavior. In boys, acting out is often antisocial and may include behaviors such as breaking and entering a school, delinquency, or repeatedly defying parental guidelines. In girls.
acting out is more often self-destructive than antisocial, tending toward such behaviors as running away from home, becoming pregnant, or using drugs. Depressed older adolescents may also engage in acting-out behavior, but they are more likely to be aware that they are doing so. Depressed early adolescents can also exhibit a depressive equivalent called the flight to and from people. They may alternate between persistent, clingy, attention-seeking behavior and sudden withdrawal from parents and teachers. Along with such withdrawal, the adolescent may become very attached to a pet, spending considerable time alone with the animal. It can be useful to ask a young patient if he or she has a pet and how much time is being spent with it if a diagnosis of depression is suspected. Because early adolescence is characterized by concrete operational thinking, a depressed youngster is unlikely to express unhappiness verbally and may not even be able to recognize that he or she is, in fact, feeling sad. Thus, questions about mood may not be useful in diagnosing depression in such a youngster. Instead, pediatricians must learn to identify indirect, nonver. hal indicators of depression in a young adolescent, such as lack of energy in interactions. In diagnosing depression in mid-to-late adolescents, DSMIII-R criteria are more helpful, as depression in this age group has much in common with that in adults. Unlike early adolescents, mid-to-late adolescents are generally able to articulate feelings of sadness and other emotions and thoughts that can facilitate a diagnosis of depression. Symptoms in this age group include dysphoria; dimin-
Table 3. Common Symptoms of Depression in Adolescents Depressed mood Irritability, negativism Antisocial, impulsive behavior (substance abuse) Diminished interest/pleasure in most activities Boredom, apathy Self-destructive socialization as an alternative Disturbance of apetite (weight loss or weight gain) Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Low self-esteem; feelings of worthlessness or excessive guilt Diminished ability to think or concentrate Poor school work Memory difficulty Preoccupation with death and/or suicide Feelings of hopelessness, pessimism Loss of future orientation
Adapted from DSM-111-R
ished self-esteem; feelings of hopelessness; suicidal ideation; appetite changes; changes in sleep patterns, level of physical activity, or sexual behavior; and decline in academic performance (Table 3). The diagnosis of depression in mid-to-late adolescents can be aided by the administration of a standardized questionnaire, which teenagers are generally willing to complete. The most widely used questionnaire is the Beck Depression Inventory, a list of 21 statements related to depression and suicide that can be rated for relative severity. Other available questionnaires include the Children's Depression Inven(conttnues) Hospital Practice April 15. 1992
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ed growth hormone response to insulin-induced hypoglycemia may support a diagnosis of depression, but none of these tests should be used to rule out depression in an otherwise possible candidate. The etiologic factors underlying depression are too complex, incompletely understood, and unreliably associated with psychological symptomatology for any laboratory test to be of more than limited clinical usefulness in diagnosing depression (Table 4). As is the case with depression, symptoms of suicidality are widely overlooked in adolescent patients. The early identification of suicidal and presuicidal behavior in adolescents is essential to suicide prevention. Primary care physicians are on the front lines in this respect and they
(continued)
tory, the Children's Depression Scale, the Children's Depression Rating Scale, and the Reynolds Adolescent Depression Scale. Currently, there is no simple, sure biologic test for depression or for suicidality, although some laboratory tests can aid in diagnosis. Such tests include the dexamethasone suppression test, which measures adrenal cortisol secretion after the administration of 1 mg of dexamethasone (normal serum level,
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Adolescent Depression and Suicide: Rising Problems Christopher H. Hodgman & Elizabeth R. McAnarney To cite this article: Christopher H. Hodgman & Elizabeth R. McAnarney (1992) Adolescent Depression and Suicide: Rising Problems, Hospital Practice, 27:4, 73-96, DOI: 10.1080/21548331.1992.11705400 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705400
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [Monash University Library]
Date: 03 July 2016, At: 05:13
Adolescent Depression and Suicide: Rising Problems CHRISTOPHER H. HODGMAN
and ELIZABETH R. McANARNEY
UniversltyojRochester
Downloaded by [Monash University Library] at 05:13 03 July 2016
In adolescents, as in adults, most depressive persons are not suicidal, and many suicidal persons are not depressed. However, accurate diagnosis and treatment of depression in adolescent patients is essential to suicide prevention. Unfortunately, depression and suicidality remain widely undiagnosed and untreated in the adolescent population.
OVer the past 40 years, the rate of adolescent suicide in the United States has increased dramatically. Suicide is now the third leading cause of death among American adolescents, with rates roughly three times as high today as in 1950 (Figure 1). Diagnoses of adolescent depression have also been on the rise. Although some have questioned whether this increase indicates an actual rise in the prevalence of adolescent depression or simply reflects improved diagnostic methodologies, the fact remains that adolescent depression is widespread. By one estimate, mild to severe depression affects 36.3% of adolescents. Self-reported depressive symptoms for 14- to 15-year-olds run as high as 41.7% for boys and 4 7. 7% for girls. While some relationship between depression and suicide in general would seem obvious, it is by no means straightforward. As in adults, most depressive adolescents are not suicidal, and many suicidal adolescents are not depressed. However, depression is known to be a primary risk factor for suicide. Thus, accurate diagnosis and treatment of depression in adolescent patients is essential to suicide prevention in this population. Unfortunately, depression and suicidality have been, and remain, widely undiagnosed and untreat-
Dr. Hodgman is Associate Professor, Department of Psychiatry and Department of Pediatrics, and Dr. McAnarney is Professor and Associate Chair (Academic Affairs), Department of Pediatrics, University of Rochester School of Medicine. Dr. Hodgman is also Director, Division of Child and Adolescent Psychiatry, and Dr. McAnarney is Chief, Division of Adolescent Medicine, Strong Memorial Hospital, Rochester, N.Y.
ed in the adolescent population, as in the population at large. Indeed, a clear majority of cases of adolescent depression are untreated in the United States. On a more positive note, significant advances have been made over the past decade in the conceptualization, diagnosis, and treatment of depression and suicidality. Pediatric depression in general is no longer viewed as a problem distinctly different from adult depression, to be managed by mental health professionals in nonmedical settings. Adolescent depression and suicidality are now seen in the context of a lifelong continuum of affective disorders, defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM-III-R), and falling within the purview of general psychiatry, which now includes child psychiatry as a medical subspecialty. This reconceptualization of adolescent depression and suicidality has resulted largely from the pharmacologic revolution in psychiatry and a decade of research into the biology of depression and suicide. Although much remains to be learned, it is now known that at least some, if not all, forms of depression and suicidality are characterized by common biochemical features, such as low levels of biogenic amines (e.g., norepinephrine and serotonin), which are believed to be essential for transmission of positive-affect stimuli in the central nervous system. FUrthermore, several types of depression have been shown to respond to treatment with the same range of antidepressants, when administered in conjunction with psychological support. These findings should not be interpreted to mean, however, that all depression and suicidality Hospital Practice April 15, 1992
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are caused exclusively by biologic and genetic factors or share a single etiologic agent. Depression and suicidality in adolescents, as in adults, may be triggered by a variety of psychological and environmental as well as biologic factors, including personalloss, anniversaries of emotional trauma, season of the year, viral illness, and chemicals. This multifactorial view of depression and suicidality does not invalidate the hypothesis that these conditions may share a common biochemical pathway. Studies have suggested, for example, that availability of biogenic amines in the central nervous system can be influenced by
thoughts, just as thoughts and emotions can be influenced by neurochemicals. The statement that psychological factors may trigger depression is also consistent with the hypothesis that genetics may play a role in all forms of depression, although this hypothesis has yet to be confirmed empirically. A variety of studies have shown that genetic abnormalities underlie at least some forms of depressive illness, such as bipolar disorders. Electrophoretic evaluation of DNA fragments has revealed defects at specific chromosomal locations in some depressive patients. Expression of these abnormal-
Figure 1. According to a 1991 study by Charles E. Irwin, Jr., and colleagues at the University of California, San Francisco, motor vehicle injuries were by far the most frequent cause of death in older adolescents (aged 15 to 19 years) in the United States from 1950 to 1986. In the same period, however, the incidence of suicide increased 200%, from less than 3/100,000 to about 10/1 00,000-a rise that enabled suicide to surpass cancer, cardiovascular disease, and homicide and become the third leading cause of death in older adolescents.
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Hospital Practice Aprlll5, 1992
ities is incomplete, however, pointing to the role of psychological and environmental factors in determining if a genetic defect manifests as depression. Genetic factors may also underlie suicidality, according to some research. Studies of Old Order Amish families in the United States have revealed in some families an inherited tendency to depression, in still others a tendency to suicide, and in others a tendency to both depression and suicide (Figure 2). Other studies indicate that children adopted from families with a history of suicide into families with no such history are more likely to kill themselves than are children adopted from families with no history of suicide. It is possible that the genetic inheritance in some of these patients is a tendency to have inadequate levels of serotonin or norepinephrine in the central nervous system, predisposing them to dysphoria, impulsivity, or affective responses to situations. Confirmation of this hypothesis awaits further genetic studies and a more complete conceptualization of the organic etiology of depression and suicidality. Understanding of adolescent depression and suicide has been advanced in recent years not only by research into the biology of these conditions but by a variety ofclinical, epidemiologic. and social scientific studies as well. It is nowknown,forexample, thatsignificant comorbidity of depression and other medical and psychiatric conditions exists, and that depression tends to go undiagnosed and untreated in most of these cases. Psychiatric conditions often accompanied by depression include anxiety disorders, eating disorders, conduct disorders, borderline states, and substance abuse (which, in the case of alcohol, may function as
Downloaded by [Monash University Library] at 05:13 03 July 2016
Figure 2. In a retrospective study of Pennsylvania's Amish, Janice A. Egeland and James N. Sussex of the University of Miami found presumptive evidence of genetic factors in suicide and affective disorders such as depression. The evidence included this six-generation pedigree, which contains six cases of ascertained suicide, two of suspect-
self-medication for depression by temporarily raising serotonin levels in the central nervous system). Depression also accompanies serious physical illness in some, but surprisingly not the majority, of adolescent patients. Again, depression is rarely co-diagnosed and treated in these cases, although our experience at the University of Rochester Medical Center has shown that antidepressant medications can be administered successfully to such
ed suicide, and 19 of bipolar, unipolar, or other affective disorders (diagnosed according to criteria used in research involving deceased subjects). Other psychiatric illnesses, some undiagnosed, were also noted. An affective disorder was diagnosed in five ascertained and one suspected suicide. (Adapted from JAMA 254:915, 1985)
patients in conjunction with the medications prescribed to treat the primary physical illness. FUrther studies have contributed to the articulation of risk factors, both internal and external, for adolescent suicide. Depression and other psychiatric morbidity; stressful life events, such as parental divorce or a death in the family; an unstable, violent home life; a family history of suicide, drug and alcohol abuse, and psychiatric illness; homosexuality; and personality
characteristics such as self-derogation, intropunitiveness, and poor problem-solving skills have all been associated with an increased risk of suicide in adolescent patients. Other studies have investigated societal factors underlying the increased prevalence of adolescent suicide in recent decades. It has been suggested, for example, that the breakdown of the family and traditional beliefs and the increase in geographic transiency have contributed to Hospital Practice April 15. 1992
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the erosion of social and psychological support systems that formerly buffered adolescents against life stresses, such as economic hardship and personal loss, thus protecting against suicidality. Concomitantly with advances in research of adolescent depression and suicide, physicians have gained much clinical experience over the past decade in the diagnosis and treatment of these conditions. Given the abundance of current information and experience relevant to adolescent depression and suicide, primary care practitioners-in particular, pediatricians-need no longer view these conditions as lying entirely outside the scope of their medical practice. Indeed, it is critical that family physicians, pediatricians, and other primary care practitioners become aware of the symptoms, diagnostic methodologies, and treatment approaches to adolescent depression and suicidality and take an active role in their management in consultation with psychiatric specialists. Accordingly, this article reviews current knowledge about the epidemiology, etiology, symptomatology, diagnosis, and treatment of depression and suicidality in adolescent patients. Statistics tracking the incidence of adolescent suicide over the years, although clear in showing an upward curve, are complicated by a variety of factors, beginning with inconsistency in the very definition of adolescence. One easy definition is that it represents the second decade of life, from 10 to 19 years of age~ In most statistical analyses, adolescents are divided into two subcategories: early or young adolescents, aged 10 to 14 years, and mid-to-late or older adoles76
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cents, aged 15 to 19 years. One national data-gathering organization includes 20- to 24-yearolds in the older adolescent category. Such inconsistencies make comparisons of data difficult. For the purposes of this discussion, we will define adolescents as youths in the second decade of life. Further complicating the mortality figures for adolescent suicide is that a number of suicides are recorded as accidental deaths, which are the leading cause of death among adolescents by a wide margin. According to the National Center for Health Statistics, motor vehicle and other accidents accounted foradeathrateof66.6/100,000 in male adolescents 15 to 19 years of age, and 18.5 for the 10to 14-year-olds in 1987. For females of the same age groups in that year, the numbers were 25.1 and 7.0, respectively. Suicideconsistently a leading cause of adolescent deaths in recent years-accounted for 16.2 and 2.3 deaths per 100,000 in the older and younger adolescents, respectively. For females, the comparablenumberswereabout one fourth those for males-altogether a total of 2,152 deaths. (Homicide and suicide rates for adolescents tend to be very close. In 1987, for example, the homicide rate for older adolescent males was 15.3/100,000. Until 1985, homicide was the third leading cause of death in adolescents, but it is now exceeded by suicide in this age group. Of the 51.0/100,000 male and 22.2/100,000 female motor vehicle deaths among older adolescents in 1987, some were no doubt "successful" suicides masquerading as accidents. The exact number of suicides hidden in accident reports is, of course, impossible to determine. But it is known that almost as many
adolescent suicides are caused by impulsiveness as by depression-a fight with a boyfriend ending in an intentional car crash, for example. It has been demonstrated that more than half of adolescent suicidal behavior occurs after less than 30 minutes' deliberation, and a quarter with less than 15 minutes' deliberation. It can be concluded, therefore, that impulsive suicides make up some proportion of fatalities listed as accidents each year and that actual suicide rates are somewhat higher than reported. Statistics reveal other important demographic features of adolescent suicide relevant to its diagnosis. Adolescent boys are roughly four to five times as likely to commit suicide as are adolescent girls, although adolescent girls are much more likely to engage in nonlethal suicidal behaviors. There are roughly 50 to 200 times as many "unsuccessful" suicide attempts as completed suicides among adolescents annually, which indicates that suicide rates are a woefully inadequate measure of the prevalence of suicidality in the adolescent population. Firearms and explosives are the leading instruments of self-inflicted death among adolescent boys and girls alike, with handguns accountable for more than 80% of adolescent suicides. The prevalence of adolescent depression is difficult to determine accurately, in part because different diagnostic methodologies have yielded widely varying results. Stuart Kaplan and colleagues at State University of New York, Stony Brook, have estimated that from 13% to 28% of adolescents may be mildly depressed, 7% moderately depressed, and 1% to 3% severely depressed. Other investigators (continues)
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have published comparable findings. with estimates of major depression running as high as 9% for adolescent girls and 4% for adolescent boys. Research indicates that the reported incidence of adolescent depression and suicidality increases significantly when symptoms are vigorously sought. In a study that our group conducted at a general medical clinic for adolescents, it was found that when all adolescents attending the clinic for any reason were asked eight standard questions about depression and suicidality, diagnosis of these conditions doubled (Table 1). When the questioning was discontinued, rates of diagnosis returned to their previous levels. Admittedly, however, self-reported symptoms of depression and suicidaltty in teenagers must be viewed with some skepticism, given a proclivity among adolescents to self-dramatize. Nevertheless, we feel that the findings of this study reflect a general tendency among physicians to overlook symptoms of depressive illness and suicidality in adolescent patients. Our view is supported by a repeatedly demonstrated clinical fact: Questions about depression and suicide are rarely asked of patients of any age as part of routine medical history taking. Even when relevant questions are asked, SYmptoms of depression and suicidality are rarely considered exhaustively. This accounts, in part, for the widespread underdiagnosis of depression and suicidality in adolescent patients. Efforts to determine prevalence of adolescent depression are further complicated by depression being both an illness
and an appropriate response to major loss-an abnormal syndrome and a normal behaviorin which many of the same features may overlap. Furthermore, depression may present in adolescents as a normal response to the intense developmental stresses that characterize that phase of life. Differences between the normal response of depression and the abnormal syndrome of depression may be subtle; the pathology may be less pronounced and of shorter duration than the normal response, for example. But certain psychological features do distinguish the two: Loss of selfesteem and, in severe cases, loss of reality testing characterize the syndrome, but not the normal behavior of depression. It should be noted that both forms of depression in adolescents are underdiagnosed. Even when physicians look for depression in adolescent patients, a variety of factors can conspire to make an accurate diagnosis difficult. First, there is the problem of shifting nomen-
clature. Physicians trained before the pharmacologic revolution in psychiatry are confronted today by DSM-III-R, which has rendered obsolete many of the old familiar categories of depression, offering a nomenclature reflecting advanced understanding of its etiology. Previously, depression was viewed as either neurotic or psychotic, reactive or endogenous, primary or secondary. The discovery that patients with all of these types of depression responded to the same range of antidepressant medications called those dichotomies into question and prompted a shift in the DSM-III and DSM-III-R to primarily de. scriptive diagnoses for depression (Table 2). While this change in nomenclature may be viewed on the whole as an improvement. it nevertheless has limitations. For example, only those types of depression for which the organic etiology has been clearly demonstrated (e.g., the use of antihy(conttnues)
Table 1. A Mood Survey Used by the Authors The following questions will help us learn how you are feeling about yourself. Please note that completing this questionnaire is voluntary. For confidentiality purposes, your name will not be needed on this form. Instructions: Please circle the number 1, 2, or 3, depending on how much the question applied to you. During the past year, how often have you been bothered or troubled by: Not at All
Somewhat
Much
1
2
3
Having trouble going to sleep or staying asleep
2
3
Feeling unhappy, sad, or depressed
2
3
Feeling too tired to do things
Feeling hopeless about the future
1
2
3
Feeling nervous or tense
1
2
3
Worrying too much about things
2
3
Feeling that life isn't worth living
2
3
2
3
Feeling like hurting myself
1
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pertensive medications such as propranolol or reserpine) are diagnosed in DSM-111-R as "organic mood disorder, depressed." However, as has been stated, it is likely that all depression has an organic component, whether the initial cause of the depression is biologic, psychological, or a combination of the two. Etiologic, and therefore diagnostic, uncertainties will persist in this area until a complete biologic conceptualization of depression is achieved. Diagnostic ambiguities such as these pose a major challenge
to the psychiatric specialist charged with fine-tuning a diagnosis ofdepression in an adolescent patient. But the pediatrician or other primary care physician faces an equal challenge in making an initial, general diagnosis of depression in such a patient. In this preliminary stage of evaluation, the practitioner's key diagnostic tool is the medical history. Primary care physicians must become familiar with the different ways depression presents in younger and older adolescents and learn to ask the right questions of adolescents of different ages. For very young patients, of course, much of the
Table 2. Current Depressive Syndromes in Adolescence Classification
Symptomatology, Course
Major depressive episode (unipolar)
Full depressive picture without episodes of mania and lasting months if untreated
Family history of depression and alcoholism common
Bipolar disorder, depressed
Full depressive picture after previous episodes of mania; cycles of variable duration
Family history of bipolar disorder, alcoholism very common
Cyclothymia, depressed
Milder, briefer form of bipolar disorder
Often misdiagnosed as character pathology
Organic mood disorder (depressed)
Full depressive picture following exposure to agents or pathogens (hallucinogens, viruses, endocrine disorders)
Removal/treatment of a predisposing condition may cure, or depression may take same course as major episodes
Dysthymia ("neurotic depression")
Chronic (at least one year in adolescents), mild, with secondary disturbances. Insidious onset; predisrosing constitutiona factors
Although milder in degree, secondary disturbances and impulsiveness pose distinct suicidal risk
Adjustment disorder with depressed mood
Stress is identifiable and its alleviation should end the disorder.
Often misapplied when removal of untreated adverse circumstances alone does not terminate depression
Bereavement
Full biologic signs of depression may occur, but usually self-esteem and reality testing are retained.
May last a year or more. Patterns more variable than usually accepted.
Adapted from DSM-111-R
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medical history will be provided by parents. If a parent's assessment contradicts that of the child's, the child's view should take precedence, as a parent may tend to minimize a child's distress. The fact that depression presents differently in adolescents of different ages points to the limitations of relying strictly on DSM-III-R criteria for diagnosis of adolescent depression. While these criteria are essential to diagnosis, they may miss adolescents who are too young to verbalize, or even to identify, certain classic symptoms of depression-such as dysphoric moodin themselves. Thus; it is useful to supplementDSM-III-R cii.teria with a developmental approach to diagnosis that recognizes stage-specific symptoms of depression in adolescents of different ages and "depressive equivalents"-a phrase coined by Irving Weiner at the University of South Florida-in young adolescents who lack some of the classic presentations of depression. The developmental approach to the diagnosis of adolescent depression takes into account basic biologic, psychological, and cognitive differences that distinguish younger adolescents from older ones. Early adolescence is a stage characterized by rapid physical growth and "concrete operational thinking"-a cognitive style focused on the here-and-now. Mid-to-late adolescents have experienced most of their physical growth and move into "formal operational thinking"-a cognitive style that allows them to think abstractly, to reflect on their feelings and the feelings of others, and to think about the future. These differences between early and mid-tolate adolescents are reflected in the ways depression presents
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and is or is not articulated by those patients. In early adolescence, a primary symptom of depression is concentration difficulty, as it is in depressed patients of all ages. A diagnosis of depression should be seriously considered for a young person who has been doing well in school and suddenly shows a sharp decline in academic performance. This is a useful indicator of depression because quantitative documentation is available in the form of school records, which may help to pinpoint the onset of depression in a young patient. Early adolescent depression is also suggested by persistent boredom and restlessness. This is not the kind of periodic boredom and restlessness that affects most early adolescents from time to time but an unabated disquiet that immobilizes the adolescent and is not relieved by efforts of parents or teachers. Fatigue and preoccupation with somatic symptoms-bellyaches, headaches, backaches, joint aches-are also common symptoms of early adolescent depression. Although some preoccupation with the body is normal for youngsters at this stage, persistent somatic complaints are not. These complaints tend to be very generalized but are often quite debilitating, causing an adolescent to miss school and make repeated visits to the doctor's office or emergency room for the srune symptoms. Nothing the physician or parent does seems to provide relief. Another of the depressive equivalents in early adolescence is acting-out behavior. In boys, acting out is often antisocial and may include behaviors such as breaking and entering a school, delinquency, or repeatedly defying parental guidelines. In girls.
acting out is more often self-destructive than antisocial, tending toward such behaviors as running away from home, becoming pregnant, or using drugs. Depressed older adolescents may also engage in acting-out behavior, but they are more likely to be aware that they are doing so. Depressed early adolescents can also exhibit a depressive equivalent called the flight to and from people. They may alternate between persistent, clingy, attention-seeking behavior and sudden withdrawal from parents and teachers. Along with such withdrawal, the adolescent may become very attached to a pet, spending considerable time alone with the animal. It can be useful to ask a young patient if he or she has a pet and how much time is being spent with it if a diagnosis of depression is suspected. Because early adolescence is characterized by concrete operational thinking, a depressed youngster is unlikely to express unhappiness verbally and may not even be able to recognize that he or she is, in fact, feeling sad. Thus, questions about mood may not be useful in diagnosing depression in such a youngster. Instead, pediatricians must learn to identify indirect, nonver. hal indicators of depression in a young adolescent, such as lack of energy in interactions. In diagnosing depression in mid-to-late adolescents, DSMIII-R criteria are more helpful, as depression in this age group has much in common with that in adults. Unlike early adolescents, mid-to-late adolescents are generally able to articulate feelings of sadness and other emotions and thoughts that can facilitate a diagnosis of depression. Symptoms in this age group include dysphoria; dimin-
Table 3. Common Symptoms of Depression in Adolescents Depressed mood Irritability, negativism Antisocial, impulsive behavior (substance abuse) Diminished interest/pleasure in most activities Boredom, apathy Self-destructive socialization as an alternative Disturbance of apetite (weight loss or weight gain) Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Low self-esteem; feelings of worthlessness or excessive guilt Diminished ability to think or concentrate Poor school work Memory difficulty Preoccupation with death and/or suicide Feelings of hopelessness, pessimism Loss of future orientation
Adapted from DSM-111-R
ished self-esteem; feelings of hopelessness; suicidal ideation; appetite changes; changes in sleep patterns, level of physical activity, or sexual behavior; and decline in academic performance (Table 3). The diagnosis of depression in mid-to-late adolescents can be aided by the administration of a standardized questionnaire, which teenagers are generally willing to complete. The most widely used questionnaire is the Beck Depression Inventory, a list of 21 statements related to depression and suicide that can be rated for relative severity. Other available questionnaires include the Children's Depression Inven(conttnues) Hospital Practice April 15. 1992
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ed growth hormone response to insulin-induced hypoglycemia may support a diagnosis of depression, but none of these tests should be used to rule out depression in an otherwise possible candidate. The etiologic factors underlying depression are too complex, incompletely understood, and unreliably associated with psychological symptomatology for any laboratory test to be of more than limited clinical usefulness in diagnosing depression (Table 4). As is the case with depression, symptoms of suicidality are widely overlooked in adolescent patients. The early identification of suicidal and presuicidal behavior in adolescents is essential to suicide prevention. Primary care physicians are on the front lines in this respect and they
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tory, the Children's Depression Scale, the Children's Depression Rating Scale, and the Reynolds Adolescent Depression Scale. Currently, there is no simple, sure biologic test for depression or for suicidality, although some laboratory tests can aid in diagnosis. Such tests include the dexamethasone suppression test, which measures adrenal cortisol secretion after the administration of 1 mg of dexamethasone (normal serum level,
