Adolescent Depression and Suicide - PowerPoint

Document Sample
Adolescent Depression and Suicide - PowerPoint Powered By Docstoc
					Adolescent Depression and Suicide
Amy Cheung, MD Department of Psychiatry University of Toronto

Outline
Issues with Diagnosis Suicide in Adolescence Focus on Treatments Clinical Implications Case Presentation

Depression in Adolescence
Nationally, 8% endorsed depressive disorder


4% in males, 11% in females 1.6% in males, 7% in females

Maritimes 4% (lower than national average)


60% recurrence rate before reaching adulthood Only 50% are diagnosed before adulthood and only ½ of those who are diagnosed receive appropriate treatment

Depression in Adolescence
Provider Attitude
 

Lack of confidence in treatment Lack of understanding of research evidence Fluctuating nature Significant role of psychosocial stressors Nature of adolescence

Natural History
  

Depression in Adolescence
Difference from Depression in Adults


  

Irritability most likely presenting mood symptom versus low mood in adults Reactivity of mood Less neurovegetative symptoms Response to medications
 Remission rates same as placebo with TCA‟s

 Slightly better rates than placebo with SSRI‟s

Depression in Adolescence
Gender Differences
  

Prepuberty-males>females Post-puberty-females>males ?cause of differences
 Self-esteem  Hormonal  Vulnerability to stressors

Depression in Adolescence
Differential Diagnosis
  

Normal mood swings Bipolar Disorder Anxiety Disorder Eating Disorder Substance Abuse Personality disorders

Comorbid Disorders
 



Depression in Adolescence
Normal mood swings
    

Functional impairment Family history/traits Scales/instruments Collateral information Time

Depression in Adolescence
Bipolar Disorder
    

Time limited episodes of elevated mood Family history Collateral information Time Scales

Depression in Adolescence
Anxiety Disorder
    

Temporal association between symptoms Which is more dysfunctional Family history/traits Collateral information Treatment

Depression in Adolescence
Comorbid Disorders


Personality Disorders (including Conduct)
 Self-harm/Suicidality  Poor judgment  Irritability



Substance Abuse
 Amotivation



Eating Disorders
 Low mood due to nutritional deficiencies

Suicide in Adolescence
What do we know?


Survey of adolescents in Canada in 2002
 13.5% nationally

Males 8.8%, Females 18.4%  Rate lower in the Maritimes = 11.1%  Males 8%, Females 14.5%




Survey of adolescents in US in 2001
 19% had seriously thought about suicide  15% had a specific plan for suicide

Suicide in Adolescence
What do we know about diagnoses?
 >90% had at least one psychiatric

diagnosis  >50% had more than 2 diagnoses  49% with affective disorder  24% with comorbid substance abuse  18% with comorbid conduct disorder  21% with comorbid anxiety disorder

Suicide in Adolescence
Males
 Higher rates of Conduct Disorder and

Substance Abuse  Older males more likely to be intoxicated  Males more likely to use irreversible means

Females
 Higher rates of mood disorder  Higher rates of past attempts  More likely to use overdose as means of self-

harm

Suicide in Adolescence
What about other risk factors?
 Younger victims had less intent  Younger victims affected by parent-child

conflict  Older victims affected by romantic relationships and legal/disciplinary issues  No evidence of differential risk from family history

Suicide in Adolescence
What do we know about other risk factors?


“Contagion Effect”
 Anecdotal reports of clusters  Statistical support for time-space clusters  Evidence of media influence-increased rates

after media coverage of real or fictional suicide  Social desirability  Increase in clinically significant suicidal ideation (associated with depression)

Treatment
Goals
 

Resolution of symptoms Functional Improvement  Relationships  Academic/Vocational

Treatment Options
Psychotherapy
  

Cognitive Behavioural Therapy Interpersonal Therapy Other SSRI‟s

Antidepressants


Psychotherapies
Cognitive Behavioural Therapy (CBT)




Examines cognitions and its‟ influence on mood Numerous studies (individual or group) showing effectiveness
 Question about comparison group  TADS results

Psychotherapies
Interpersonal Therapy




Examines the connection between interpersonal relationships and mood Few studies - in “normal” settings Family Therapy Psychodynamic Psychotherapy Supportive Therapy/Counselling

Other
  

Interpretation of Efficacy Data
MEDICATION
Fluoxetine (March ‟04) Fluoxetine (Emslie ‟97) Fluoxetine (Emslie ‟02) Paroxetine (Keller ‟01)* Paroxetine Paroxetine Citalopram (Wagner ‟04) Citalopram Sertraline (Wagner ‟03) ** .

MHRA
+ + + + -

FDA
+ + + + -

*Negative in primary outcome but positive in many secondary outcomes **Two studies: pooled were positive; separate, 1 trended to positive, 1 negative

Efficacy Data (CGI)
MEDICATION
Fluoxetine (March ’04) “TADS” Fluoxetine (Emslie ’97) Fluoxetine (Emslie ’02)

Drug
61% (Drug and CBT 71%) 52% 61%

Placebo
33% (p=0.02) 36.8% (p=0.03) 35% (p=0.001)

Paroxetine (Keller ’01)
Paroxetine Paroxetine Citalopram (Wagner ’04) Sertraline (Wagner ’03)

66%
69% 65% 47% 63%

48% (p=0.02 )
57.3% (NS) 46% (p=0.005) 45% (NS) 53% (p=0.05)

.

OVERALL
Medication and therapy both can be effective Best is combination treatment  Better acute improvements in symptoms  More complete remission of disorder  Better functional status  Better self-reported quality of life

SAFETY: Psychotherapy
“Adverse events” with psychotherapy




Incidence of emergent suicidality was 12.5% Self-reported suicidal thoughts at intake were a significant predictor of emergent suicidality, even when suicidality was denied at intake interview
Bridge et al., 2005

IN THE NEWS…
 FDA Public Health Advisory (2004):


Black box warnings that recommend close observation of adult and pediatric patients treated with antidepressants for worsening of depression or the emergence of suicidality

SAFETY: Medications
 General Safety and Adverse Events


Treatment Group
 Range from 47.5 to 92.5%



Placebo Group
 Range from 35.3 to 79.3%



Most common are neurological (i.e., dizziness, headache) and GI disturbance (i.e., nausea)

SAFETY
 Discontinuation due to Adverse Events


Up to 12% Up to 12% Up to 6%

 Serious Adverse Events


 Mania


SAFETY
 Suicide Related Events


Treatment Group
 Range from 2 to 12%



Placebo Group
 Range from 0 to 7%



Most studies reported
 Different terminology/definitions

 Example of „emotional lability‟
 Previously not considered an AE

Overall relative risks (RR) of suicidal behaviour or ideation by drug
Drug Celexa Luvox Paxil Relative Risk (95% CI), MDD trials 1.37 (0.53, 3.50) No MDD trials 2.15 (0.71, 6.52) Relative Risk (95% CI), all trials, all indications 1.37 (0.53, 3.50) 5.52 (0.27, 112.55) 2.65 (1.00, 7.02) 1.52 (0.75, 3.09) 1.48 (0.42, 5.24) 4.97 (1.09, 22.72)

Prozac * 1.53 (0.74, 3.16) Zoloft 2.16 (0.48, 9.62) Effexor XR 8.84 (1.12, 69.51)

Remeron
Serzone

1.58 (0.06, 38.37)
No events

1.58 (0.06, 38.37)
No events No events
Source: FDA website

Wellbutrin No MDD trials

Overall relative risks of treatment-emergent agitation or hostility by drug in depression trials
Drug Celexa Paxil Prozac * Relative Risk (95% CI), MDD trials 1.87 (0.34, 10.13) 7.69 (1.80, 32.99) 1.01 (0.40, 2.55)

Zoloft Effexor XR Remeron Serzone All drugs

2.92 2.86 0.52 1.09 1.79

(0.31, (0.78, (0.03, (0.53, (1.16,

27.83) 10.44) 8.27) 2.25) 2.76)
Source: FDA website

* Note that TADS data are NOT added to Prozac

Data From Meta-Analyses
 Based on emergence of suicidality
 Number needed to Treat = 9  Number needed to Harm = 56
Bridge et al., 2005

Data From Other Studies (Epidemiological/Observational)
 Areas with increased antidepressant prescription rates have lower rates of completed suicides Olfson et al., 2003  Treatment of at least 6 months reduced the likelihood of suicide attempt compared with antidepressant treatment for <8 weeks Valuck et al., 2004

Data From Other Studies (Epidemiological/Observational)
Post-Mortem toxicology of adolescents after suicide showed few had taken antidepressants
Gray D et al., 2003; Isacsson G et al., 2005; Leon AC et al., 2004; Leon et al., 2006

Clinical Recommendations




A careful assessment is critical in cases where the clinician suspects depression in children and adolescents. If a diagnosis is made, patients and families need to be educated about the illness and the options available for treatment. It is also vital for clinicians to evaluate for any prior history of suicidal behaviours and to evaluate this frequently in subsequent visits. If medication is required, families and patients need to be fully informed about the risks and benefits of antidepressant treatment. Antidepressants should be initiated at a low dose (equivalent of 5-10 mg of fluoxetine) with increases every 2 weeks if no significant adverse events emerge.

Clinical Recommendations




Families and patients need to be fully informed about the possible risk of the emergence of suicidal behaviours with antidepressant treatment. Families should closely monitor for worsening depression, worsening or new onset of suicidality, and other behavioural side effects. Families may wish to utilize tools available (i.e., National Alliance for Mental Illness; Families for Depression Awareness) to aid in this process. The FDA suggests weekly face-to-face monitoring for the first 4 week of antidepressant treatment or with any subsequent dose adjustments in children and adolescents.

SOURCES
 Published clinical trials  Unpublished reports of clinical trials  ACNP Task Force:
http://www.acnp.org/exec_summary.pdf  FDA: http://www.fda.gov/ohrms/dockets/ac/cder04.html  MHRA: http://www.mhra.gov.uk/news/2003.htm