Depression in adolescents commonly presents with changes in mood, behavior, physical symptoms, and mental/emotional state. Genetics, biological changes during puberty, and life stressors can contribute to depression risk. Symptoms affect body systems and daily functioning. Treatment involves screening, diagnosis, counseling, medication, and support systems to improve symptoms and prevent relapse. The goals are symptom reduction and normal functioning.
2. LEARNING OBJECTIVES
• Ability to recognize various symptoms of a major depressive disorder (MDD)
• Know the pathological changes and affects on each of the body systems in response to
depression
• Identification of modifiable and non modifiable factors of the disease process
• Know common interventions for depression based on level of symptoms present
• Review Concept map with treatment options
• Identify the medications choices used as treatment
• Understanding the use of technology to identify and help treat patients
3. WHAT IS DEPRESSION?
de·pres·sion
dəˈpreSH(ə)n/
1. feelings of severe despondency and dejection.
"self-doubt creeps in and that swiftly turns to depression"
PSYCHIATRY
a mental condition characterized by feelings of severe despondency and dejection,
typically also with feelings of inadequacy and guilt, often accompanied by lack of
energy and disturbance of appetite and sleep.
“Genetic, biologic, developmental, cognitive and experiential processes have all been
associated with development of depression” (Davis, 2005).
4. HOW DEPRESSIVE SYMPTOMS PRESENT?
• Mood
• Depressed or irritable mood
• Mood Changes with out cause
• Behavior
• Kids do not verbalize sadness but show it in a low frustration tolerance, social
withdrawal or somatic complaints
• Decreased interests in sports activities complaints of boredom
• Physical symptoms
• Fatigue or decrease in energy
• Sleep disturbance ( insomnia or hypersomnia)
• Weight change (gain or loss) and appetite change
• Inability to concentration
• Physical harm such as cutting, and self mutilation
• Mental/Emotional
• Feelings of worthless or hopeless
• Feeling guilty for their feelings and thoughts
• Thoughts of death or suicide
5. GENETICS
• Depression runs in families
• Children with one depressed parent are 3x more likely to have
MDD than children of non-depressed parents
• Need to discuss familial history of bipolar disorder, depression,
anxiety and other mental disorders
“Its effects can be seen into adulthood with poor psychosocial functioning and a decrease in life
satisfaction” (Lewinsohn et al., 2003)
6. ADOLESCENT FEMALE CHANGES
• Appearance of breast buds
• (between 8 and 12 years of age), followed by
breast development (13-18)
• Development of pubic hair (11-14)
• Growth spurt begins (average age, 10), which
adds inches to height and hip circumference
• Menses begins (average age, 12, normal age
range between 9 and 16)
• Enlargement of ovaries, uterus, labia, and
clitoris; thickening of the endo-metrium and
vaginal mucosa
• Appearance of underarm hair (13-16)
• Dental changes, which include jaw growth and
development of molars
• Development of body odor and acne
7. ADOLESCENT MALE CHANGES
• Testicular enlargement, beginning as early as 9-
½ years of age
• Appearance of pubic hair (10-15)
• Onset of spermarche, or sperm found in the
ejaculate
• Lengthening of genitals (11-14)
• Rapid enlargement of the larynx, pharynx, and
lungs, which can lead to alterations in vocal
quality (i.e., voice cracking)
• Development of body odor and acne
• Changes in physical growth (average age, 14),
first seen in the hands and feet, followed by the
arms and legs, and then the trunk and chest
• Weight gain and increases in lean body mass
and muscle mass (11-16)
• Doubling of heart size and vital lung capacity,
increase in blood pressure and blood volume
• Growth of facial and body hair, which may not
be completed until the mid-20s
• Dental changes, which include jaw growth and
development of molars
•
9. CARDIOVASCULAR AND HEMATOPOIETIC
• The size and strength of the heart, amount of blood volume, and systolic blood pressure increase, while the
pulse and basal heat production decrease.
• The blood volume increases steadily throughout childhood, and is higher in boys than in girls at adolescents,
which could in part related to the increase in the amount of muscle mass in pubertal boys.
• “During this period, physiologic response to exercise change drastically; performance improves, especially in
boys, and the body is able to make the physiologic adjustments needed for normal functioning after exercise
is completed” (Whaley, Wong,& Murphy, 1997).
• Recurrence of cardiovascular problems is linked more closely to depression than to smoking, diabetes, high
blood pressure, or high cholesterol.
• If untreated in adolescents it can follow them into adulthood where depression raises the risk of dying after a
heart attack, as heart disease is also a trigger for depression.
• Elevated heart rate and blood pressure, elevated blood glucose and shunting of blood from the digestive
organs to the brain help the body respond to perceived threats.
10. RESPIRATORY
• “The respiratory system grows during puberty” (Geiger-
Bronsky & Wilson, 2008). The respiratory system in
adolescents is also changing and reaches that of an adult.
• The respiratory rate is the same as an adult at 12-20
breaths per minute. In some situations delayed
development may be a result of chronic diseases (such as
malabsorption or chronic asthma) that are serious enough
to retard the developmental process or environmental
factors (such as stress or poor nutrition)” (Murphy,
Whaley & Wong, 1997).
• “Children and adolescents with chronic medical
conditions are at higher risk for depression (Davis, 2005).
• The changes that take place are follows: the upper airway
gets longer, wider and thicker, the location of the larynx
shifts, the alveoli enlarge and the total surface area
increase. There are some changes regarding the gas
exchange that differ between male and females during
puberty. “Men inhale and retain more O2 and exhale
more CO2, with each breath than women. The result is
grater alkali reserve. The oxygen dissociation curve also
changes during adolescence, as the percentage of
hemoglobin saturation of O2 and the PO2 of blood
increase. Bronchi and bronchioles- increase proportionally
in size and vital capacity. Sex difference become more
apparent, as lung size capacity is greater in males than in
females. Respiration infections decrease after puberty due
to larger airway lumens, full development of the immune
system, and completed lung growth. (Geiger-Bronsky &
Wilson, 2008)
11. FLUID AND ELECTROLYTE
• “The caloric and protein requirements during this time are higher than at almost any other time of life”
(Murphy, Whaley & Wong, 1997). There is an increased need for calcium, iron and zinc during such
growth periods to help with skeletal growth, bone tissue growth and increases in muscle mass and
blood volume. A decrease in any of those could cause other medical problems that can then lead to
other co morbidities.
• Adolescents may require an increase in fluid intake to make sure they are replacing the electrolytes and
water they are losing during sporting activities. May see an increase in boys appetites as they are
growing and exerting more energy related to increased physical activity, however may see a decrease in
the amount girls are eating as a result of the body image issues they are may be going through, which
can lead to eating disorders.
• With those who are depressed they many times fall short on the required amount of electorlytes
needed, as they have poor nutritional behaviors.
12. URINARY
• Girls may be more susceptible to an iron deficiency due to
blood loss related to their menstrual cycle. “Other
hormonal changes of puberty, such as growth hormone
and insulin-like growth factor-I release, have the potential
to accelerate renal disease through transforming growth
factor-β activation, as evaluated for diabetic nephropathy”
(Beier, Green & Meyer, 2010).
• Young women develop urinary-tract infections at more
than three times the rate of young men. One probable
reason why is that the female urethra, at just one and a
half inches long, affords germs easy access to the bladder.
The male urethra, in contrast, measures eight inches in
length.
• Adolescents with depression have riskier behavior, and
can result in the potential for STD, which in turn can affect
the urinary system and also the social life of the
adolescent.
13. REPRODUCTIVE
• For most girls the initial indication of puberty is the appearance of breast buds that occurs usually around age
9- 13, followed by growth of pubic hair, about 1.5 to 2 years they experience their first menstrual period. Girls
also have an enlargement of the ovaries, uterus, vagina, labia and breast in addition to the growth of pubic
hair. This alone is a trigger for girls of this specific age group to be stricken with anxiety and depression.
• Changes that occur in males begin with enlargement of their testicles, and increased looseness of the scrotal
area. This is usually followed by the growth of pubic hair, and penile enlargement begins and all continue
throughout mid puberty. They also experience changes in their voice as well as the development of facial hair.
With all of these changes taking place this could also cause many young boys to be depressed or anxious,
especially if they are a late bloomer and others have developed before they have, it could cause a poor body
image.
• It has been hypothesized that women presenting with episodes of depression associated with reproductive
events (i.e., premenstrual, postpartum, menopausal transition) may be particularly prone to experiencing
depression, in part because of a heightened sensitivity to intense hormonal fluctuations.
14. ENDOCRINE
• The endocrine system is the control system the
helps many produce many of the hormones to help
the body function and regulate the body’s daily
activities.
• “Hormonal abnormalities are believed to
contribute to the development of depression.
Dysregulation of the hypothalamic-pituitary-
adrenal axis (HPA), the system that manages the
body’s response to stress, has been shown to
contribute to depression” (Davis, 2005).
• In females, the ovaries produce estrogen, and
increased levels in the female cause’s changes to
progesterone which is the hormone that is
increased during pregnancy.
•
• Male’s testes produce testosterone, both
testosterone and estrogen are present in males and
females, however there are higher levels of
testosterone in males and estrogen in females
which is primarily responsible for the changes
occurring during this time.
• During a stress response, the body’s adrenal glands
secrete three important hormones called
epinephrine, norepinephrine, and cortisol (a
corticosteroid). These stress hormones are
responsible for the symptoms experienced when
the body is in fight or flight mode.
15. GASTROINTESTINAL
• Depression can affect the appetite. Some people cope by overeating or binging. This can lead to weight
and obesity-related illnesses like type 2 diabetes. Others lose their appetite or fail to eat nutritious food.
Eating problems can lead to stomachaches, cramps, constipation, or malnutrition. Symptoms may not
improve with medication.
• Many adolescents have problems with eating disorders, therefore many problems can persist effecting
the GI system- problems with bowel movements or lack of, stomach problems, reflux etc.
• These problems can also interfere with the adolescents daily activities, causing problems socially for
them
16. MUSCULOSKELETAL
• Childhood obesity can have a harmful effect on the body in a variety of ways. According to the CDC, children diagnosed as
obese or overweight are more likely to have:
• High blood pressure and high cholesterol, both of which are risk factors for cardiovascular disease.
• Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.
• Breathing problems such as sleep apnea and asthma. Females are at a higher risk of asthma than boys during adolescences
• Liver disease, gallstones and gastro-esophageal reflux.
• A greater risk of social and psychological problems.
• Too much weight also can seriously impact the growth and health of bones, joints, and muscles.
• Bones grow in size and strength during childhood. Excess weight can damage the growth plate — the area of developing
cartilage tissue at the end of the body's arm, leg and other long bones. Growth plates regulate and help determine the
length and shape of a bone at full growth or maturity.
• Too much weight places excess stress on the growth plate which can lead to early arthritis, a greater risk for broken bones,
and other serious conditions, such as slipped capital femoral epiphysis and Blount's disease.
17. NEURAL AND SENSORY
• Depression causes neurological changes in the brain resulting in mental, emotional and physical
changes.
• Alteration in the production of neurotransmitters such as serotonin and norepinepherine, and the
functioning of neurotransmitter receptor sites.
• Adolescents show significant neuropsychological progress in the years leading up to adulthood
• The brain continues to increase in total volume until the age of approximately 14 years.
• Epilepsy is the most common neurological disorder of adolescence, that is very commonly diagnosis
hand in hand with depression
18. IMMUNE SYSTEM
• Depression weakens the immune system,
particularly natural killer T-cells which help protect
the body from carcinogens (cancer-causing agents).
A weakened immune system also affects the body’s
inflammatory response. The NIHM reports that this
physical effect of depression has been related to an
increased incidence of osteoarthritis, asthma, heart
disease and autoimmune disorders.
• Depression and stress may have a negative impact
on the immune system, making you more
vulnerable to infections and diseases.
• Findings suggest that immune system dysregulation
may be associated with adolescent MDD, with an
imbalance of Th1/Th2 shifted toward Th1, as
documented in adult MDD.
19. MODIFIABLE FACTORS
Increase awareness of signs and symptoms
Promote a safe and supportive environment
Provide adolescents with educational information to help them understand and cope with the changes
they are going through, let them know this is normal
Encourage them to stay active
Recognize family history if present and act early if treatment is needed
Keep them busy, do not allow yourself to ignore the symptoms of depression by saying they are that way
because they are a teenager
Review and monitor social media (Facebook, Twitter, Snapchat etc.) for anything that would identify signs
of depression
Can modify behaviors that are putting them at risk
20. NON MODIFIABLE FACTORS
Genetics play a role in the adolescent with depression, those children with parents who have been
diagnosed with a mental disorder are 3 times more likely to be diagnosed with one as well
Many adolescents with co morbidities are more likely to be faced with depression or anxiety as a result of
the other disease process
Chemical changes taking place during adolescences can cause a imbalance, and due to the fact their brains
are not fully developed to cope with things as an adult it can make things much harder for them to accept
and understand
21. CRITERIA FOR DIAGNOSIS:
DEPRESSED MOOD OR ANHEDONIA + 4 OTHERS
• S - sleep, insomnia or hypersomnia
• I - interests
• G - guilt, feeling worthless or hopeless
• E - energy
• C - concentration
• A - appetite
• P - psychomotor retardation or agitation
• S - suicidal thoughts or recurrent thoughts of death
22. GATHERING HISTORY
• Best to interview both parent and youth
• Parents better at reporting behavioral
disturbances & time course of symptoms
• Youth better at reporting on
mood/anxiety/sleep
• Youth often have depressed mood or SI that
parent is unaware of
• R/O neglect, abuse physical or sexual
• Recent stressors
• Anxiety symptoms
• Unusual thoughts or psychotic symptoms
prodrome to schizophrenia
• Symptoms of mania now or past
need for sleep, hypersexuality or grandiosity
• FHx of suicides or bipolar disorder
23. CONCEPT MAP
Screening for Major
Depressive Disorder
(MDD)
No Symptoms Mild Symptoms
Counseling/ Support
System
Reassessment
Continue Counseling/
Possible Medical
Treatment with
medication
End Treatment
Moderate/Severe
Symptoms
Suicide Risk
Assessment
Treatment
Medication
Treatment
Medication
Adherence
Continue treatment
End Treatment
Therapy (including
Hospitalization)
Communication and
Reassessment
Continue Treatment
End Treatment
25. TREATMENT OPTIONS
• Psychoeducation – this is a group effort by all who surround the adolescent, discuss treatment options
• Parents
• School
• Friends
• Individual psychotherapy
• Supportive
• Cognitive Behavioral Therapy
• Interpersonal Psychotherapy
• Family therapy – counseling and
• Medication
26. TREATMENT GOALS
• Response – significant reduction in symptoms or no symptoms present for 2 weeks
• Remission – period of > 2 weeks and < 2 months with few symptoms
• Recovery** – absence of symptoms for > 2 months
**Recovery is the goal
27. PSYCHOEDUCATION
• All patients should receive
• Information about symptoms and typical course with discussion (depression is a illness; not a sign of weakness;
no one’s fault etc.)
• Discussion of treatment options- allowing the adolescent to participate in the care planning
• Placing patient in sick role temporarily may be helpful and temporary school accommodations could help with
treatment
28. SUPPORTIVE TREATMENT
• All patients should receive supportive treatment and in some cases this
could be all that is required for milder depressive symptoms
• Meeting frequently to monitor progress
• Active listening and reflection
• Restoration of hope
• Problem solving
• Improving coping skills
• Strategies for adherence
• If not improving in 4 weeks, reassess and identify what type or if more
specific treatment is needed
29. TREATMENT OPTIONS
If moderate to severe depression is identified, start with specific treatment
based on those severe symptoms.
• Individual psychotherapy – some kids may not be willing to open up to a counselor or
other adults, but my lean more on technology to display their feelings
• Cognitive Behavioral Therapy
• Interpersonal Psychotherapy
• Family therapy
• Medication
Severe depression – start meds and other referrals
30. MEDICATION TREATMENT OPTIONS
• Selective Serotonin Reuptake Inhibitors
• Selective NE Reuptake Inhibitors
• Other antidepressants
• Tricyclic Antidepressants
• Typical duration of medication treatment – 6 to 12 months after response present. Relapse high if stop
within 4 months of symptom improvement.
31. MEDICATION-SSRIS
• *Fluoxetine (Prozac) - age 8
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Citalopram (Celexa)
• *Escitalopram (Lexapro) - age 12
• Fluvoxamine (Luvox)
*FDA approved for the treatment of MDD under age 18
33. SSRIS – COMMON SIDE EFFECTS
• Nausea and diarrhea – 5HT receptors numerous in gut, need to titration slowly, this side effect remits
with exposure
• Headache – usually remits with time
• Agitation, impulsivity or activation – 3-8% pts
• Insomnia
• Fatigue or sedation (more common w/paroxetine, citalopram or escitalopram)
• Sexual side effects – low libido or anorgasmia
34. THINGS ADOLESCENTS CAN DO TO RELAX IF FEELINGS
OF STRESS OF DEPRESSION ARE PRESENT
• Running
• Weight lifting
• Going for a walk
• Playing a sport
• Listening to music
• Dancing
• Read
• Write in a journal
• Call a friend
• Talk to someone
• Take a hot shower
• Imagine a relaxing place in my mind
• Deep slow breathing
• Do a puzzle
• Crafts
• Drawing/coloring
35. TECHNOLOGY
• Young people often manifest warning signs for depression online. A 13-year old girl
with depression may reveal uncharacteristic and repeated irritability in Facebook posts and comments.
Or, a 16-year old girl might reveal feelings of hopelessness and irregular sleep patterns on her blog. A
17-year old boy might confide via YouTube video feelings of alienation or hopelessness.
• Parents and mentors who are connected both offline and online with young people should carefully
watch for warning signs. These warning signs should be taken very seriously to help young people get
the support they need.
36. SUMMARY
• Major depression occurs in 8% of adolescents
• Screening can be done in schools or medical office
• Identification of and diagnosis of type of depression is first step
• The many changes the adolescent is going through is stressful enough and many who are not able to cope, or
understand all of the changes occurring are highly likely to be diagnosed
• Mild depression can sometimes be treated with support and a safe supportive environment
• Moderate depression would begin talk therapy, and the discussion of medications if needed. Reassess the
plan every 6-8 weeks
• Severe depression treatment likely to use meds or combination meds + therapy as first step, close monitoring
would be needed to prevent any suicidal or self harm events from occurring. Frequent visits, with discussion
and monitoring of the medications as suicide is a potential side effect of various medications used for
treatment of depression.
• Monitor the adolescents use of technology, social media, text messages etc. to identify any behaviors that
require attention
37. REFERENCES
• Beier, U., Green, C., & Meyers, K. (2010). Caring for adolescent renal patients. Kidney International, 77(4), 285-291.
http://dx.doi.org/10.1038/ki.2009.462
• Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment A
Meta-analysis of Randomized Controlled Trials Bridge JA, JAMA. 2007;297:1683-1696
• Davis, N. M. (2005). Depression in children and adolescents. The Journal of School Nursing, 21(6), 311-317.
• Dubuis, J. (2016, March 25). Puberty: Physiology. Retrieved from http://www.gfmer.ch/Endo/Lectures_10/Puberty_
Physiology.htm
• Early Prediction of Acute Antidepressant Treatment Response and Remission in Pediatric Major Depressive DisorderTao RA. J.
Am. Acad. Child Adolesc. Psychiatry, 2009;48(1):71-78.
• Gabbay, V., Klien, R., Alonso, C., Babb, J., Nishawala, M., De Jesus, G., . . . Gonzalez, C. (200, May). Immune system
dysregulation in adolescent major depressive disorder. Journal of Affective Disorers, 115(1-2), 177-182.
doi:10.1016/j.jad.2008.07.022
• Geiger-Bronsky, M., MSN, APNP, BC, & Wilson, D., RN, MSN, RRT. (2006). Respiratory Nursing: A core curriculum. Springer
Publishing Company.
• McNeely, C., MA, DrPH, & Blanchard, J. (2009). The teen years explained: A guide to healthy adolescent development.
Baltimore, MD: John Hopkins University.
• Murphy, A. C., Wong, D. L., & Whaley, L. F. (1997). Study guide Whaley & Wong's Essentials of pediatric nursing, fifth edition
(5th ed.). St. Louis, MO: Mosby-Year Book.
• Soares, C. N., & Zitek, B. (2008). Reproductive hormone sensitivity and risk for depression across the female life cycle: A
continuum of vulnerability?Journal of Psychiatry & Neuroscience : JPN, 33(4), 331–343.
• The Treatment of Adolescent Suicide Attempters Study (TASA): Predictors of Suicidal Events in an Open Treatment Trial Brent
DA, J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(10):987-996
