Problem 2: depression part 2
1. Sad babies, toddlers and adolescents
Fergusson, David M., Woodward, Lianne J.,. (2002). Mental Health, Educational, and Social Role
Outcomes of Adolescents With Depression. Arch Gen Psychiatry, 59(3), 225–225.
doi:10.1001/archpsyc.59.3.225
Abstract
Background: this study used longitudinal data to examine the extent to which young people with
depression in mid adolescence (14-16) were at increased risk of adverse psychological outcomes later
in adolescence (16-21).
Methods: 21-year longitudinal study of 1265 New-Zealand children.
Results: 13% developed depression between 14-16. Young people with depression were significantly at
risk of later major depression, anxiety disorders, nicotine dependence, alcohol abuse of dependence,
suicide attempt, educational underachievement, underemployment and early parenthood. This was
similar for boys and girls. There are 2 major pathways linking early depression to later outcomes:
1. Direct link between early depression and increased risk of later major depression or anxiety
disorders.
2. Associations between early depression and other outcomes were explained by the presence of
confounding social, familial and individual factors.
Conclusion: early depression is directly associated with increased risk of later MDD and anxiety
disorders. Linkages between early depression and other outcomes appeared to reflect the effects of
confounding factors.
Introduction
There are 2 questions being addressed in this article:
1. To what extent are young people who develop depression in mid adolescence (14-16) at
increased risk of subsequent mental disorders, academic underachievement and reduced life
opportunities?
2. What are the pathways that may link adolescent depression to later outcomes?
There are 3 possible pathways:
1. There may be a direct effect of depression on later outcomes. Depression may lead to impaired
educational underachievement etc.
2. 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.
3. The linkages between early depression and later outcomes are mediated by the presence of
comorbid disorders.
Results
Relations between depression and later outcomes: Adolescents with depression were at
increased risk of a range of subsequent outcomes between age 16-21 (later depression =
highest, anxiety disorder, nicotine dependence, alcohol, suicidal behaviour, school failure and
reduced likelihood of university = lowest)
, - The relationship between adolescent depression and later outcomes was similar for
boys and girls.
Social, familial and individual factors associated with depression: Adolescents with and
without depression had similar SES. However, depressed adolescents were significantly more
likely to have been exposed to sexual abuse and parental change during childhood. They also
had lower IQ scores, tendencies to neuroticism and higher rates of deviant peer involvement.
Relationships between depression in adolescence and later outcomes, adjusted for
confounding factors:
- Clear relationship between adolescent depression and later depression (OR 3.5).
- The associations between adolescent depression and other outcomes (nicotine
dependence, alcohol etc.) were explained by confounding factors (parental change,
childhood sexual abuse, IQ etc.).
Dus: directe link tussen vroege depressie en latere depressie en indirecte link tussen vroege depressie
en latere uitkomsten (IQ, abuse etc.).
Discussion
Conclusions about link between depression and later outcomes:
Young people with depression in adolescence were at increased risk for a range of adverse
outcomes (subsequent depression, anxiety, nicotine, early parenthood etc.).
Depression in adolescence was associated with other adverse factors (higher rates of adverse
familial circumstances, lower IQ, neuroticism, anxiety disorder etc.).
There are 2 proven routes by which adolescent depression was associated with later social
maladjustment:
1. There is a direct link between depression in adolescence and increased risk of later depression
and anxiety (3x higher risk, 2x higher risk of anxiety).
2. There is evidence for a non-causal relationship with depression and other outcomes (substance
abuse, suicide attempt, underachievement, unemployment, early parenthood). The link
between depression and these other outcomes were associated with a range of adverse social,
familial and personal factors. Rather, the contextual factors that were associated with an
increased risk of depression were associated with increased risk of later adverse outcomes.
Clinical implications:
1. Depressive disorders are frequently recurrent.
2. The later outcomes (suicidal behaviors, underachievement, unemployment etc.) are not
consequences of early depression, but arise as a result of common social, familial and personal
factors that contribute to the early depression and to later outcomes.
Limitations:
New-zealand kids only.
Retrospective reporting of depressive findings, unclear if it met clinical criteria.
Self-reported data so again unsure if it met clinical criteria.
Large number of outcome and covariate factors.
Zhou X, Teng T, Zhang Y, Del Giovane C, Furukawa TA, Weisz JR, Li X, Cuijpers P, Coghill D, Xiang Y,
Hetrick SE, Leucht S, Qin M, Barth J, Ravindran AV, Yang L, Curry J, Fan L, Silva SG, Cipriani A, Xie P.
, Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for
acute treatment of children and adolescents with depressive disorder: a systematic review and
network meta-analysis. Lancet Psychiatry. 2020 Jul;7(7):581-601. doi: 10.1016/S2215-0366(20)30137-1.
Abstract
Background: depressive disorders are common in children and adolescents. Antidepressants,
psychotherapies and their combination are often used, however, evidence on these is inconclusive.
Methods: They did a systematic review and network meta-analysis on this topic. They included
placebo-controlled and head-to-head trials. They included 71 trials with depressive disorders moderate
to severe.
Results:
- Efficacy: fluoxetine + 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 + 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.
- 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 + CBT and vilazodone.
Interpretation: fluoxetine (alone or in combi with CBT) seems to be the best choice for the acute
treatment of moderate-to-severe depressive disorder in children and adolescents. The effects might
vary, however, between individuals.
Introduction
Young patients with depression have more serious impairments in social and educational functioning
and have an increased risk of smoking, substance abuse, obesity and suicide compared to adults with
depression. Moreover, depression is the second or third leading cause of death in adolescence.
Previous meta-analyses have shown that antidepressants, except for fluoxetine, do not offer a clear
advantage over pill placebo for many individuals, an some antidepressants might increase risk of
suicidality.
The aim of this study is to synthesise all available evidence on commonly used antidepressants,
psychotherapies and their combinations for the acute treatment of depressive disorder in children and
adolescents.
Methods
Antidepressants that were included: TCAs , SRRIs (fluoxetine), serotonin norepinephrine reuptake
inhibitors and other drugs.
Therapies: CBT, behavioural therapy, family therapy, interpersonal psychotherapy, psychodynamic
therapy, problem-solving therapy, supportive therapy and others.
Outcomes were efficacy, acceptability and suicidality.
71 RCTs were included in this study, comparing 16 antidepressants, 7 psychotherapies, 5 combinations
and three psychological controls or pill placebo.
Results
Efficacy:
