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Mood Disorders in Adolescence


Stanley Kutcher, DCPsy, FRCPC
Professor and Head of Psychiatry, Dalhousie University
Psychiatrist-in-Chief, Queen Elizabeth II Health Sciences Centre
Halifax, NS

 
q What is the most common mood disorder in adolescence?
a Clearly the most common mood disorder is depression. And it affects different proportions of teenagers at different times in the adolescent life cycle. In the earliest part of adolescence, that is pre-puberty or at the time of puberty, the incidence of depression is low - probably 1 to 2% - of the adolescent population. But by the time adolescence is over, that is around 19 to 20 years of age, the prevalence of the disorder has risen to about 8%, which is the adult prevalence.
   
q Do adolescents also suffer from dysthymia or anxiety disorders?
a Yes, they certainly suffer from dysthymia. Very often in adolescence, dysthymia is a prolongation of mood problems which have begun in childhood. But sometimes dysthymia does onset for the first time in adolescence. The other part about this is that often dysthymia in childhood progresses to become a major depressive disorder in adolescence and then that gives rise to what we call double depression, meaning a depressive episode superimposed upon dysthymia.
   
q Do mood disorders present differently in the adolescent than they do in the adult?

a There are a number of symptoms which people should look for in terms of presentation. Essentially, the characteristics of an adult mood disorder are found in adolescents and we use the same criteria to make the diagnosis in adolescents as we do in adults. So we feel that the disease is essentially the same. However, the developmental specifics for adolescents are as follows. Many teenagers will present with an atypical depression, that is, they will present with mood reactivity, with hypersomnia (that is, sleeping more hours in a day than not), and with carbohydrate cravings, binge eating and possible weight gain. The other thing that often presents in adolescence is that irritability as opposed to frank depression can be an initial presentation of a depression. But again, the irritability is sustained, and it's persistent and it's different from the teenager's usual functioning. The other thing about adolescence is that it's not that the mood disorder is diagnosed differently but that very often, the signs of the mood disorder are misinterpreted. For example, boredom in adolescence is often identified as a problem. When we really look at what boredom means to the teenager, it really means that they are having a lack of pleasure and not enjoying life. It's called boredom but what it really is anhedonia. So the teenager will present complaining of boredom but actually what they have is anhedonia. In teenagers, it's really important to differentiate what they say they are presenting with or what their parents say they are presenting with and what they actually have. Because again, if we stay with the issue of boredom, the parents may say the child is bored, or amotivated or not interested in school when that is simply a reflection of a loss of interest or pleasure, which is anhedonia.
   
q What about hostility or rage in teenagers? Often they seem hostile and angry.

a Most teenagers are not hostile and angry so that's a myth. Hostility and rage in teenagers should be taken as hostility and rage in adults. First of all, if the hostility and rage is different from their usual presentation, we have to determine whether or not it is irritability, and if it is irritability, would that be because of a mood disorder or very often, could that irritability be part of a substance abuse problem and they are going through withdrawal or else through the effects of the substances. Secondly, there are other disorders which present in adolescence which are psychiatric illnesses associated with hostility and rage. For example, in the hypomanic stage of bipolar illness, mood lability is often associated with irritable outbursts, and rage outbursts. Intermittent explosive disorder, which is a disorder characterized by rage outbursts, often begins to really manifest itself in adolescence as well. So the take-home message here is that irritability and rage are not characteristic of normal adolescent behavior, that if they do occur, the issues to look at are: Is there a psychiatric disorder that's causing it or is it a substance abuse that's causing it?
   
q Teenagers are often difficult to talk to. How do you get them to tell you about their feelings and the difficulties they may be having?

a There is a real art to learning how to talk to teenagers. There are a number of good hints: one is don't be judgemental. The second is, don't come on as a big authority figure. The third is, that you raise the hypothesis, that is, you tell them what you think they have and identify it, and then give them permission to discuss it. We use those kinds of techniques and others and it can take years to be able to actually deal with them. Important personality issues for the therapist working with teenagers is to be completely real and not phony, to give them a sense that they can trust you and you have to be trustworthy with them. But at the same time, making it clear what the boundaries are. For example, if the kid is going to hurt somebody or going to hurt themselves, then that is a boundary that other people become involved.
   
q If an adolescent is reluctant to take an antidepressant medication - perhaps doesn't want to admit that they are depressed - what do you say to try to persuade them that this is the right and necessary thing to do?

a What I do is that I don't look at it that way. I identify what the problem is and we come to an agreement on the diagnosis and the problem. Then we look at alternative treatments and I always describe to adolescents the various types of treatments that are available. That is, supportive therapy, sorting out your problems, interpersonal counselling, cognitive therapy and medications. We sit down and we figure out what the teenager herself or himself would prefer, and we try to provide that kind of treatment so that not all teenagers get medication and not all teenagers get particular kinds of psychotherapies. I suggest to them that what the best thing to do is either start with the psychotherapy, and then if that doesn't work, go on to medications, or else to begin medications with psychotherapy at the same time.
   
q The treatment for adolescent depression sounds as if it's really quite similar to that used for adults. Or does it differ in any way?

a Yes, it is very similar to that used for adults. The only thing that is really different is adapting the type of psychotherapy to fit the developmental tasks of the adolescent. So you are dealing with adolescent developmental issues in your psychotherapy rather than adult developmental issues. But the general types of therapies are the same. In pharmacotherapy, two things are clearly different. The first thing is that adolescents have a very high placebo response to medications. In every single study that has ever been done in adolescents looking at double-blind, placebo-controlled trials, they have placebo rates ranging from 40 to 55% - which is a huge placebo response rate. You don't find those kinds of placebo response rates in adult studies. So a lot of teenagers, even if they have been profoundly depressed for months and months and months, seem to get better in a placebo method. The other thing that is different is that there is clearly no good evidence that the tricyclic type of antidepressants are useful in teenagers. The tricyclic antidepressants cause an awful lot of side effects in teenagers, and they are cardiotoxic and kids kill themselves with tricyclics. So we don't use tricyclics in adolescent depression.
   
q What else should a GP be doing to ensure their adolescent depressed patient does well?

a There are a number of things. One thing is that if a teenager is depressed, very often they are having troubles at school. And sometimes - with the teenager's permission - contacting the school and helping the school sort out the kid's difficulties, is often useful. For example, they may not be able to take all their courses, they may need some deferment of exams, so being an advocate for the teenager can be helpful. The second thing is in many cases, intervention with the rest of the family is also important. We know that these disorders run in families; very often, there will be a family member with depression or substance abuse which hasn't been properly treated and the GP can provide treatment for that family member. In some cases, you will have parents who don't believe the teenager is depressed, they see the depression as a lack of moral fibre - if only they just worked harder, everything would be fine. That attitude really isn't helping the teenager and in those cases, helping the parent or the other family member deal with the depression is an important part of therapy.
   
q What do you do if your depressed teenagers talks seriously about suicide?

a That's a really difficult area and here, the level of comfort dealing with a suicidal teenager depends on the practitioner's experience probably more than anything else. Very often, teenagers will be suicidal. The issue here is how suicidal are they before one blows the whistle (i.e., admits them to a hospital setting). You don't want to admit a kid to hospital or put them in a confined environment if you don't have to for a couple of reasons, one being that there is tremendous stigma to going into a hospital. Secondly, it can be counter-therapeutic, that is, the kid can learn that simply by going into a hospital, they avoid their problems. So that is not a good message to tell kids. On the other hand, if a kid is really seriously at risk, you have to take steps to ensure they don't kill themselves. So there are a number of ways that you deal with this, but the most important factor is the trust factor in the relationship that the therapist has with a teenager. The stronger the relationship and the stronger the trust factor, the better kids will be at going on with the treatment and not killing themselves. A number of practical things here: I, for example, I have a cell phone and I use the cell phone for teenagers who are suicidal to be able to contact me any time they want. But they also realize that the phone is sometimes shut off, so that they are able to do a couple of calls before they get through. We also talk about help lines and hot lines. I also talk to them about accessing the emergency room, and the other important part about this, is that if they are really quite suicidal, sometimes the parents are a positive factor and can be helpful too. In any case, whatever the issue is, whenever you see a kid, if you think the kid is suicidal, you have to make the assessment, you have to identify it, and sometimes it boils down to really just dealing with the kid and the problems that they are having with life - and always, always, always instilling hope. "Yes things are terrible, no they haven't gotten better, but I'm not going to give up on you and you can't give up on yourself - we are going to work at this together until we beat it", and instilling hope is essential.
   
q If the onset of depression or perhaps the first episode of bipolar illness is fairly early on in their teenage years, are they more likely to have persistent or recurrent illness for the rest of their lives?

a The data on teenage depression is pretty clear. If they have had a depressive episode during their adolescent years, 60 to 70% of them will have another episode in the next 5 years. So, obviously depression onsetting in the adolescent years is a pretty chronic and malignant disorder. Same thing with bipolar disorder. If the bipolar illness onsets in adolescent years - in other words, they have had both a depression and a mania during adolescence - the data that we have shows that bipolar illness is a very virulent illness, it has a high degree of recurrence and it is a very serious disorder.
   
q At what point would you recommend a GP refer their adolescent patient to a psychiatrist?

a It depends on the skills of the GP. A number of GPs are uncomfortable about treating teenagers, and they may be unsure about what to do. So my first approach would be to encourage the GP to increase their skill sets - to take courses or seminars on how to treat teenagers with depression. But even if that happens, there are some people who don't have the necessary skill sets. The other time to recommend referral is if the teenager has tried a course of treatment and they are not responding to treatment. The third situation is a teenager is really suicidal or has a mixed substance abuse, personality disturbance and depression, that would be a person to refer. One of the difficulties of course is that there is a paucity of child and adolescent specialists in Canada, so that not all GPs have the luxury of referring a teenager to a specialist in that area. They may have to refer them to a psychiatrist who in some cases may not have all the skill sets necessary for treating teenagers, although they generally have more than the GP.
   
q Any bottom line take home messages, Dr Kutcher, when handling these often difficult patients?

a One thing is that you've got to like them, and you have to stay with them. And if you like them and stay with them, and don't give up on them, you'll be rewarded.
   

 

 

 

 


Over one million Canadians suffer from some form of depressive illness.