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Summary 3.4 Affective Disorders: Problem 2 (Depression part 2)
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PSYCHOLOGY– PROBLEMS------------------------------------------------------------
3.4 Affective disorders
Problem 2: Depression part 2
Learning goal 1: Sad babies, toddlers and adolescents
» FERGUSSON: MENTAL HEALTH, EDUCATIONAL AND SOCIALE ROLE OUTCOMES OF
ADOLESCENTS WITH DEPRESSION
Background: this study examines the extent to which young people with depression in mid
adolescence (14-60) were at increased risk of adverse psychological outcomes in later
adolescence and young adulthood (16-21).
Methods: data were gathered during a 21-year longitudinal study of a birth cohort of 1265
children (New Zealand). These young people had been studied at birth, 4 months, 1year,
annual intervals to age 16 years, and again at ages 18 and 21 years.
Aims of the study: (1) To what extent are young people who develop depression in mid
adolescence (age 14-16) at increased risk of subsequent mental disorders, academic
underachievement, and reduced life opportunities? and (2) What are the pathways that may
link adolescent depression to later outcomes?
Results: Thirteen percent of the cohort developed depression between ages 14 and 16.
- Young people with depression in adolescence were at significantly increased risk of
later major depression, anxiety disorders, nicotine dependence, alcohol abuse or
dependence, suicide attempt, educational underachievement, unemployment, and
early parenthood.
- These associations were similar for girls and boys.
- The results suggested the presence of 2 major pathways linking early depression to
later outcomes.
1. First, there was a direct linkage between early depression and increased risk of
later major depression or anxiety disorders.
2. Second, the associations between early depression and other outcomes were
explained by the presence of confounding social, familial, and individual factors.
- Depression in adolescence was associated with other adverse factors. These factors
included higher rates of exposure to adverse social and familial circumstances, lower
IQ, higher levels of neuroticism, and higher rates of comorbid adolescent disorders,
including anxiety, conduct disorders, and substance abuse.
Conclusions: young people having early depression were at increased risk of later adverse
psychosocial outcomes. There was a direct linkage in which early depression was associated
with increased risk of later major depression and anxiety disorders. Linkages between early
depression and other outcomes appeared to reflect the effects of confounding factors.
Introduction: There is emerging evidence to suggest that young people showing early-onset
depression or depressive tendencies are at risk for several adverse outcomes, including a
further depressive episode, impaired social functioning, low academic achievement, and a
range of other mental health problems, such as anxiety disorders, substance abuse, and
suicidal be haviors. These linkages between early depression and later outcomes are
thought to reflect the effects of early- onset depression on normal development and the
continuities of depressedmood across time. Less is known about the pathways linking early
depression to later outcomes.
In general, there are 3 pathways that may explain linkages between early depression and
later outcomes.
1. First, there may be a direct effect of depression on later outcomes. For example,
depression may lead to impaired educational achievement and reduced life
opportunities.
2. Second, it is possible that the associations between early depression and later
outcomes are noncausal and reflect the presence of antecedent factors that are
, associated with increased risk of depression and other adverse outcomes. For
example, early exposure to child abuse may be associated with increased risk of
depression and other adverse outcomes.
3. Finally, it is possible that the linkages between early depression and later outcomes
are mediated by the presence of comorbid disorders. Therefore, the associations
between early depression and later substance abuse may reflect the effects of
conduct disorder that is comorbid with early depression.
Results
Relationship between adolescent depression and later outcomes
Adolescents with depression were at increased risk of a range of subsequent outcomes
between ages 16 and 21. These outcomes included later depression, anxiety disorders,
nicotine dependence, alcohol abuse or dependence, suicidal behavior, school failure and a
reduced likelihood of entering a university. At age 21, adolescents with depression were
characterized by higher rates of recurrent employment and early parenthood. For most
outcomes, there was a significant main effect of sex, reflecting the fact that rates of
subsequent psychiatric, educational, and social role out- comes varied in sex-specific ways.
Social, familial and individual factors associated with depression in early adolescence (age
14-16)
Adolescents with and without depression had similar socioeconomic backgrounds. In
contrast, small to moderate associations were found between adolescent depression and
family measures, individual factors, and comorbid psychiatric disorders. Specifically,
adolescents with depression were significantly more likely to have been exposed to sexual
abuse and parental change during childhood. They also tended to have had lower IQ scores
at age 9, showed tendencies to neuroticism, and reported higher rates of deviant peer
involvement in adolescence. Finally, adolescents with depression had significantly higher
rates of comorbid anxiety disorders, conduct disorders, and alcohol abuse and were more
likely to smoke cigarettes.
Relationship between depression in adolescence and later outcomes, adjusted for
confounding factors
First, there was evidence of a clear and specific continuity from adolescent depression to
later depression and anxiety, even after controlling for confounding factors and comorbid
disorders. Second, in all cases, the associations between adolescent depression and other
outcomes, including nicotine dependence, alcohol abuse or dependence, suicide attempt,
educational underachievement, unemployment, and early parenthood, were explained by
confounding factors (parental change, childhood sexual abuse, IQ, neuroticism, involvement
with deviant peers, and maternal educational underachievement) associated with
depression. These results imply that the elevated rates of these outcomes among teenagers
with depression reflected the antecedent social background, familial, and personal factors
that were associated with adolescent depression and increased risk of later adverse
outcomes, rather than the direct effects of depression on later adjustment and life
experiences.
» ZHOU (2020): COMPARATIVE EFFICACY AND ACCEPTABILITY OF ANTIDEPRESSANTS,
PSYCHOTHERAPIES AND THEIR COMBINATION FOR ACUTE TREATMENT OF CHILDREN
AND ADOLESCENTS WITH DEPRESSIVE DISORDER
Background: depressive disorders are common in children and adolescents.
Antidepressants, psychotherapies, and their combination are often used in routine clinical
practice; however, available evidence on the comparative efficacy and safety of these
interventions is inconclusive.
Method: a systematic review and network meta-analysis. Included: placebo-controlled and
head-to-head trials of 16 antidepressants, 7 psychotherapies and 5 combinations of
, antidepressants and psychotherapie that are used for acute treatment of children and
adolescents with depressive disorder. 71 trials with N=9510.
Findings: Depressive disorders in most studies were moderate to severe. In terms of
efficacy, fluoxetine plus cognitive behavioural therapy (CBT) was more effective than CBT
alone and psychodynamic therapy, but not more effective than fluoxetine alone. No
pharmacotherapy alone was more effective than psychotherapy alone. Only fluoxetine plus
CBT and fluoxetine were significantly more effective than pill placebo or psychological
controls and only interpersonal therapy was more effective than all psychological controls.
Nortriptyline and waiting list were less effective than most active interventions. In terms of
acceptability, nefazodone and fluoxetine were associated with fewer dropouts than
sertraline, imipramine, and desipramine; imipramine was associated with more dropouts
than pill placebo, desvenlafaxine, fluoxetine plus CBT, and vilazodone. Most of the results
were rated as “low” to “very low” in terms of confidence of evidence according to
Confidence In Network Meta-Analysis.
- In terms of suicidality, the findings confirmed that venlafaxine is associated with an
increased risk of suicidal behaviour or ideation compared with pill placebo and ten
other interventions.
Interpretation: Despite the scarcity of high-quality evidence, fluoxetine (alone or in
combination with CBT) seems to be the best choice for the acute treatment of moderate-to-
severe depressive disorder in children and adolescents. However, the effects of these
interventions might vary between individuals, so patients, carers, and clinicians should
carefully balance the risk-benefit profile of efficacy, acceptability, and suicide risk of all
active interventions in young patients with depression on a case-by-case basis.
The primary outcomes were efficacy (depressive symptoms measured by mean overall
change scores from baseline to after completion of treatment on standardised depressive
symptom scales) and acceptability (allcause discontinuation measured by the proportion of
patients who withdrew from the study for any reason). The secondary outcome was
suicidality (measured by reported cases of suicidal behaviour or ideation).
The comparisonadjusted funnel plots of the network metaanalysis were suggestive of
publication bias for efficacy outcome in psychotherapy trials, but not for acceptability.
Network metaregression analyses showed that most modifiers did not significantly affect
the efficacy and acceptability of interventions; however, the authors found that studies in
which participants had more severe depressive symptoms at baseline were associated with
larger treatment effects, and that studies with high risk of bias were associated with a lower
dropout rate.
The findings in children and adolescents’ contrast with findings on the efficacy of
antidepressants and psychological interventions in adults with major depressive disorder, for
whom all antidepressants were more efficacious than pill placebo and all psychotherapeutic
interventions were superior to psychological control conditions. There are several possible
explanations for this difference. First, neurodevelopmental mechanisms, including robust
changes in hormones and hormonal receptors in adolescent depression, could exacerbate
emotional responses to negative social stimuli by dysregulation of the hypothalamic–
pituitary–adrenal axis. Second, the smaller number of trials and smaller sample sizes for
young patients with depression decreases statistical power for each comparison. Third,
different design methods between adult and paediatric trials could lead to a higher placebo
response rate in children and adolescents (45%) than adults (36%) based on clinician
ratings, hindering the detection of positive results for depression in children and
adolescents.
» HARMER: ANTIDEPRESSANTS AND PSYCHOTHERAPY FOR ADOLESCENT DEPRESSION:
CAN THEY BE COMPARED?
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