View episode transcript

Featured Guests

Joanna Quigley, M.D. and Alejandra Arango, Ph.D.

Objectives

• Review the neurobiology of depression.
• Determine appropriate screening tools for depression for the screening of children and adolescents.
• Differentiate between depression presentation in children versus adults.

Resources

• Mental Health Surveillance Among Children (CDC)
• Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management (AAP)

Disclosures 

Alejandra Arango, Ph.D. has disclosed a relevant financial relationship with: Vita Health - Consultant/Advisory Role, Other - Teaching, Conflict is relevant but is managed.

This relationship is relevant, this company does work in the topic area, but the relationship ended on 10/31/23.

CME

Credits available: 0.5 

To enroll for CME credit, visit our episode activity website. Visit our CME course overview page for details on CME credit, or complete this survey for social work CEUs.

Visit our podcast website for more information about this episode and the Breaking Down Mental Health podcast series.

Breaking Down Mental Health is a part of the Michigan Medicine Podcast Network. You can subscribe to Breaking Down Mental Health podcast wherever you listen to podcasts.

Transcript

Dr. Christina Cwynar:

Hello and welcome back for season two of Breaking Down Mental Health with myself, nurse practitioner, Dr. Christina Cwynar, social worker, Syma Khan and child and adolescent psychiatrist Dr. Heidi Burns. Unfortunately, Dr. Burns is unable to join us today.

Syma Khan:

This season we are focusing on depression. So here to kick us off is Dr. Joanna Quigley and Dr. Alejandra Arango. Dr. Quigley is a child and adolescent psychiatrist and pediatrician whose clinical, educational and scholarly work centers around the mental health care of children and adolescents particularly improving access to mental health care for vulnerable populations. She's been critical in supporting the Michigan Child Collaborative Care Program, a statewide teleconsultation and tele-psychiatric care program.

Dr. Arango is a licensed clinical child psychologist and clinical assistant professor at Michigan Medicine. Clinically, she's interested in working with adolescents presenting with depression, anxiety, psychosis and trauma, and for whom suicide specific interventions are a core aspect of treatment. Dr. Arango is involved in interdisciplinary training and is a member of the Youth Depression and Suicide Prevention Research Program. Dr. Arango, can you talk a little bit about what depression is and how it's diagnosed?

Dr. Alejandra Arango:

Yes, thanks for having us. So depression is one of the most prevalent mental health conditions in youth and a very serious mood disorder. And often when we say depression, we're really talking about major depressive disorder and estimates vary. But reports indicate that somewhere between 15 and 20% of youth report depression in the past year. And depression is beyond typically experienced feelings of sadness or of irritability, and it can really impact many areas of life, including our thinking, our emotions, and our behaviors. And it can really affect individual's ability to engage in their life and do the things that they enjoy or even do the things that are meaningful to them. So as far as how depression is diagnosed, this is typically done with a comprehensive psychiatric evaluation where we learn a lot about a youth. We learn about their challenges, their strengths, the ways that symptoms are impacting their lives and their goals.

But to meet diagnostic criteria for major depressive disorder based on the diagnostic and statistical manual or the DSM-5, an individual must experience at least five of the following symptoms. So the first one is depressed mood, so feeling down or irritable. The second one is anhedonia, which is really a loss of enjoyment or interest in activities. There can also be changes in sleep, which could be an increase in sleep or perhaps sleep difficulties, changes in appetite, which again can be an increase or a decrease in changes in appetite. We also observe changes in the way somebody moves physically throughout the world, and that might be so much so that others may notice. There's also decreases in amounts of energy, lowered motivation or even fatigue. As well as feelings of low self-esteem, feelings of guilt, of hopelessness, of helplessness, of worthlessness. Another symptom that we see is difficulties concentrating, so having a hard time focusing, having a hard time getting things accomplished or done, staying on task.

The final symptom that we look out for is thoughts that life is not worth living or even a desire to die. Like I shared, we have to have five of these symptoms and these symptoms need to be present for at least two weeks for most of the day and for a good portion of the day. And like we talked about earlier, symptoms really represent a notable change in how somebody is functioning or the ways that they're able to engage in their life. And what's really important to know is that depression can really look very different from person to person. And even though sometimes we have a picture of what a depressed youth might look like, that can vary.

So for one youth, an experience with depression could be characterized maybe more by depressed mood or lack of sleep and appetite changes. But maybe for another youth, their experience might be more about a loss of interest in things, feeling indecisive, struggling to concentrate or perhaps feeling worthless. And youth may have one episode of depression or they might have reoccurring episodes of depression. Depression episodes sometimes even have a seasonal pattern. So for example, depression symptoms may onset in the winter months and the severity may also vary from mild to severe.

Dr. Christina Cwynar:

Thank you for getting us started on the diagnostic criteria of what we're really looking for. And I think we all know as providers who work in this field that patients don't present as textbook. And oftentimes parents come to us saying one thing and saying things like, "This doesn't look like depression." And once we really dig into it truly is. So Dr. Quigley, can you talk a little bit about what we see when a child or an adolescent presents as depressed maybe versus an adult?

Dr. Joanna Quigley:

Yeah, thanks for that question. And this is really important, like you pointed out because a lot of times I think this gets missed or it gets brushed aside. So there are a lot of differences when we think about the way kids or adolescents might look when they are dealing with depression. As we just heard about, we can see kids present with symptoms that are very similar to adults in terms of feeling sad, having less interest in activity and feeling more withdrawn. In really young children, they're probably not going to tell us, "I'm feeling really sad or I feel really down," and we have to watch for other signs. So one thing that we often see is irritability.

So kids might be more angry or more easily upset with us. Other kids will present with symptoms more connected to their bodies. So they may tell us that they're dealing with more headaches or more tummy aches. They may not want to go to school. They may really withdraw from activities that they used to love, their sports, their music activities, activities with their friends. And as we heard about just now, we also might see changes at school. School is the main job when you're a kid. So they may have more trouble getting homework turned in, they may stop paying attention in class. They may have more trouble with respect towards teachers or peers because they're just feeling really lousy.

And also like we heard about before, they may seem more restless or distracted or they could even seem really more slowed down or more fatigued. So one story we'll sometimes hear is about an adolescent who was really engaged doing really well and then all of a sudden wants to quit swim team or all of a sudden wants to quit cheer. And then when we peel back the layers, there's been a building experience for that kid of feeling more down, feeling more withdrawn, really not having fun with things and actually feeling bad about how they're doing at everything that they're doing in life.

So other things to watch for. I do want to point out the fact that we are seeing more depression in younger kids and also seeing increased rates of suicide in younger kids. And that's why thinking about these signs and symptoms is so important. One other point I want to make is that in the younger age group, we're seeing more boys present with depression when we would typically think about the classic adolescent girl being down and depressed. We still see a lot of that in the adolescent years. But we're also starting to understand that depression not only shows up in different ways, but maybe different kids are at different risks depending on their age.

Dr. Christina Cwynar:

I vividly remember a young man, and I met him on accident. And many of our listeners know that I work in consult psychiatry, but I was sitting on a medical floor and talking with a team about a completely different patient, and he came running out of room, yelling, screaming, and we had to help support this patient. And he wasn't even admitted for mental health reasons. But in getting to know him and his family, it became very clear that he was suffering for depression and self-medicating with substances and actually was acutely suicidal. And that was actually the underlying cause for his presentation but nobody had put two and two together because he had told them that he had ingested to get high. And things like that are sometimes missed. And remembering that.

Syma Khan:

I think we often also think about behavior and that irritability and that can so often be missed or labeled or misdiagnosed. And I think it's important just reflect that that is also sometimes a key presentation for adolescents too.

Dr. Joanna Quigley:

Absolutely. And they get written off as being difficult kids or the kids that are always in trouble. And really these are warning signs for something much deeper.

Syma Khan:

Yeah, thanks so much for helping us understand just the nuances of how we see depression from an adult side, from a diagnostic perspective, and then really thinking about how we can support youth and knowing that we are still in the midst of a youth mental health crisis. So supporting our youth early in their course is ideal. Dr. Arango, can you talk a little bit about screening children and adolescents and maybe some of the different scales and their effectiveness in screening depression in adolescents? Yes,

Dr. Alejandra Arango:

Absolutely. So you're totally right. There's been several national organizations that really have highlighted the current mental health crisis in youth. And one approach to identify youth who are struggling is through screening. And so screens, we often think about them as being brief, feasible to implement tools that can be administered broadly to maybe a defined group to identify who might need additional assessment or even who might need additional support. And there are many brief tools specifically for depression. A frequently used tool is the PHQ-9, which is short for the patient health questionnaire. And this has been adapted for use with adolescents. And I like this tool because it's short. Like I said, it's only nine items and it assesses many of the symptoms of depression, including depressed mood, loss of interest, sleep changes, and one of the items actually screens for suicidal thinking. And we know that, for example, in places like primary care settings, it's recommended that youth 12 and up are screened for depression yearly.

And the PHQ-9 is a good tool for this because it's also been shown to capture some changes over time. There are definitely other tools. There's the Children's Depression Inventory or the Beck Youth Inventory for depression. There's also semi-structured tools or semi-structured interviews that are based on some of the diagnostic criteria that we discussed earlier that can be used both to screen, but also to gather additional information about how the youth is doing as well as broader questionnaires. So, I often use the Child Behavior Checklist, for example, or CBCL for short, which can provide a more comprehensive picture of several areas of how a youth is doing, including areas of concern and even some areas where the youth might be doing well. And like Dr. Quigley said earlier, many of these youth or some of these youth are presenting with suicidal thinking as well. And so, I think when we think about screening for depression, I think it's also helpful to think about screening for suicide risks specifically. And there's some wonderful tools for that.

I always like to think about the ASQ, which is short for the Ask Suicide Questions screener. And this is a publicly available screen that there's a lot of information on it on the NIMH website. So, one more thing that I wanted to say about screening is that it's really important to consider multi-informant and multi-method approaches. So, what we mean by multi-informant is asking more than one person. So, what's wonderful about working with kids is that usually they're there with somebody else, there might be a caregiver who's available. And it's important to ask both the youth and their caregiver how they're doing as far as some of the symptoms that they're presenting with or that we're concerned about because a caregiver might notice things that a youth might not be fully aware of yet.

And we also want to implement multi-method approaches. And what we mean by that is that sometimes a youth might be more likely to disclose feelings of depression or even thoughts of suicide in a paper or pencil measure, even a tablet base measure versus having to say some of these things out loud. And so, we might be capturing some youth when we're using methods or multi methods or different kinds of methods like direct screening, but also completing some of those questionnaires.

Syma Khan:

Thanks so much for sharing about screening some of the different measures that we use. Any reflections on pediatric professionals and supports for them when they're screening either in the clinic or emergency room, knowing that oftentimes that's an interface that many youth have before they may access a mental health professional if they're struggling with depression or suicidal thoughts?

Dr. Alejandra Arango:

Yeah, absolutely. And there's some nice frameworks. So, like the Zero Suicide framework, they have a really lovely website, and I think a big part of this is really, how do we create a framework and a workflow that these providers can feel comfortable using? So, there's a plan, right? Because one thing to screen and then it's a different thing to know what to do with that screen and figure out when does a screen... If a child, for example, is presenting in primary care and there's a positive screen, when does that child need to go to the emergency department versus when can things be managed in-house with different kinds of supports? And so I think using some of those frameworks as is provided by Zero Suicide to think about workflows is an important step.

Dr. Christina Cwynar:

And I think that's a good point. And even teaching our students at all levels, you have a patient presenting with SI, how do you assess that? What questions do you ask? What is the true risk? And what do you do with that? Are they presenting to a rural pediatric primary care office or are they in a more acute setting where they have more mental health supports? And what do those supports look like in each area? Knowing your resources and learning that even as a baby student as opposed to learning that on the fly when you're the one running the show and by yourself or those types of situations. So, thinking about that and teaching our students to think about that early is really important. And I think you made a really good point about, and I think we talk about this more in depth in actually our next episode. We're going to meet with Dr. Cheryl King and talk about suicide and depression, but talking or thinking about not only assessing for depression but suicide and how they are two separate things and looking at that a little bit more closely.

Syma Khan:

And just to add recognizing that for many youth and many family screening and medical settings is often safer for them or it's more accessible. And so kind recognizing that meeting that need in those settings will actually help support and really get people into care sooner and help prevent more long-term impacts on their functioning as they move into adolescents, young adulthood, even disability and adulthood and things like that. So it's really important for us to think about how this is everyone's responsibility. And I think in particular, things like Zero Suicide really do provide great resources and guidance along with the National Institute of Mental Health and a lot of other settings and part of Joint Commission recommendations too. And so there's a lot of resources for our medical professionals to access the support screening.

Dr. Christina Cwynar:

And I think this is just the beginning of the conversation that we're having. This whole season is about depression and going into more of a deep dive about medications and therapy and next steps in treatment. But one big question I always get from families is why? What's wrong with my child? What caused this? My child isn't crazy, all of those things that we hear. So, Dr. Quigley, can you talk a little bit about some of the neurobiology that we do know behind depression?

Dr. Joanna Quigley:

Yeah, I'd be happy to and start with the fact that we understand quite a bit, but there's still so much more to understand. So just generally, we know that depression as it shows up, happens for a lot of different reasons. One of the reasons that we think depression may occur on a tissue level or a cellular level is misconnections or misfiring of different types of cells in the brain, and that does include what goes on with serotonin. We used to think that it was this clean model of there's just not enough serotonin, and we know it's a lot more complicated than that now, but we do still have evidence that our medicines are pretty effective.

So, there are ways different parts of the brain are not talking to each other as effectively, and those parts of the brain are involved in recognizing other people's emotions, being able to process emotions and feelings and the parts of the brain involved in thinking as well as the parts of the brain involved in memory and decision-making. So, all these different parts of the brain we know are impacted by depression, and we're able to look at things like MRI studies of the brain and show how they may not be, as I said, talking to each other as effectively, and that may be sign or a way that depression manifests.

Another thing I want to mention here is the fact that there are risk factors for depression that we know about, and that can be points of intervention and prevention over time. So, we know for example, that there is a genetic factor to depression, so you may be at a higher risk because of your family history. We also know that having a low birth weight when you were born or maybe certain exposures during the pregnancy, that might increase your risk of depression. Additionally, having certain medical conditions can increase your risk for depression and anxiety over time. Also, being exposed to trauma or having big adverse life events can be another risk factor, and that includes bullying. And for a lot of our youth now, the way they navigate social media. So, exposures on social media, the content they're viewing, the amount of time they're spending on social media, there are a lot of concerns about that, how that is impacting the mental health of our youth.

Additionally, as was brought up before by Christina, we worry a lot about comorbidity with depression. So, we worry about the fact that kids might start using substances and use them as a way to cope, and that use can actually make their mood worse. Anxiety disorders are tightly linked with depression, so is ADHD and other conditions that we treat in psychiatry. I also want to recognize the fact that marginalized youth and minoritized youth are often at greater risk because of all of the stressors they're managing. So, we think about our LGBTQIA youth in particular and youth that are dealing with racism and other forms of targeting in their day-to-day lives that really takes a toll and increases their risk over time.

Syma Khan:

It seems really clear that there's both a significant biological component, but then also a lot of environmental components that relate to depression. And so that screening is really important as over time, those social and environmental factors may change and maybe express some genes or those two things are interplaying. So, I really appreciate that comprehensive overview. In adolescents age 12 to 17, 15.1% experienced a major depressive episode in the past year and 36.7% had feelings of persistent sadness or hopelessness in the past year. When do you think about treatment of depression and what do you typically consider? When do you consider medications, therapy or both?

Dr. Alejandra Arango:

Yes, the prevalence of depression is quite alarmingly high. And what is hopeful is that we know that there's some interventions that are helpful for some youth. And so, the behavioral intervention with the most evidence for the treatment of adolescent depression is cognitive behavior therapy or CBT. And CBT really starts with education and helping a youth and their family better understand what depression is, why it happens, how it impacts life, some of the things that we've been talking about so far. And CBT also aims to equip youth with skills to help them manage their symptoms so that hopefully they can improve over time. And a really important component of this intervention is the CBT model or sometimes we call it the CBT triangle, which really explains how our thinking and our emotions and our behaviors are all related and impact one another.

An oversimplified example of this is that a thought I'm not good at anything may impact a youth's behavior and then they might not try activities that they're interested in, which then impacts their emotions because they might feel left out or they might feel like they fail. And what CBT really does is to help youth break down some of these behavioral and thought patterns and equip them with skills for how to do these things. And so those thought patterns are broken down with strategies like cognitive restructuring, which really help a youth to learn to identify when a thought is not helpful and teach them skills for how to think flexibly. Other strategies that are part of this intervention are behavioral activation which helps the youth to really slowly engage in activities over time that are important to them. And we know that other factors like lack of physical activity and poor sleep unfortunately also contribute to and maintain depression symptoms and interventions that targeted at improving sleep schedules, habits and routines are often critical to the treatment of depression.

Similarly, finding ways to support youth as they increase their engagement in physical activities is a pretty core aspect of treatment. And these interventions often start really small, like having a youth maybe walk one time around their house and hopefully over time grow to more meaningful activities like taking daily walks. And when we think about the treatment of youth, it's so important to think about caregivers because they're really critical to supporting treatment, and it's important for caregivers to both understand depression and how it's impacting their youth's behavior, how it's impacting the way that their child is interacting with other people. But also, caregivers can play a role in supporting youth to make some of these changes that we've talked about so far and really work to reinforce their efforts.

And sometimes we've been talking about throughout the podcast, the treatment of depression may involve management of suicidal thinking and behavior. And we do this by helping youth and their families create a plan for how the youth can manage urges to self-harm. And this plan involves many things, but it involves things like coping skills, social supports, emergency resources, as well as steps to making the home environment safe. I think about behavioral intervention first, what I do all day, but we know that medications are really a core aspect of treatment of depression, and often the use of SSRIs or serotonin re-uptake inhibitors as the first line of medication-based treatments that are trialed. But as far as when medications are considered, that can really vary widely. There's research that indicates the combination of both medications and behavioral interventions can be most effective. However, this is really a family decision, and some families may choose to trial behavioral interventions first, while other times a teen may need that medication to be able to engage with some of the very challenging, oftentimes challenging behavioral interventions that we do.

And so, the best course is presenting families with a menu of options and walking them through the pros and cons so that they can make a choice that best fits their child and their family. As far as intervention, the last thing I wanted to say is that whether it's medication or behavioral intervention, even though we know these can work, they take time and sometimes they take different approaches or different trials, and it's so important to set really realistic expectations at the start and to just really stick with it because sometimes it takes a little bit to get traction, but we can see really powerful benefits sometimes too.

Syma Khan:

Dr. Quigley, anything to add thinking about treatment and what interventions to pursue when thinking about adolescents with depression?

Dr. Joanna Quigley:

A couple of things to add. And I agree, the approach is often guided by the family and preferences. If someone's in a situation when they're really concerned about the level of depression and the family doesn't feel ready, I often will set a guidepost along the line of number of weeks of continuing in psychotherapy and whether or not we see improvement and that being a good signal for us that we maybe need to consider medicine. We have a lot of choices within that family of medicine that Dr. Arango talked about. So the SSRIs, and sometimes it takes a little while to find the right fit. So, I would also say not to give up on medicines just after trying one. We also think about staying on medicine for usually at least a year at a dose that's helpful before stopping medicine. So, it's a very natural human tendency to stop medicine when you feel better, but we know that if you stick with it and you're consistent with your dosing for that period of time, that when you stop the medicine and ideally continue with some boost or episodes of therapy, you have better outcomes.

Syma Khan:

One thing that sometimes we hear is people label depression as mild, moderate, or severe. Are there any reflections that you have on what treatment approach to take when there's maybe those different labels attached to the depression and maybe who's the right provider to intervene at certain times?

Dr. Joanna Quigley:

So I think this is really helpful to think about because access is so challenging. So, a lot of the care for kids is happening in that primary care setting or even subspecialty pediatric care. I would say, for what we consider milder depression when we're seeing signs, but the impairment or the impact is manageable, that I would encourage the primary care provider to help the family engage in accessing therapy definitely. And then considering a medicine at that time, if the family feels ready. Once we're in the moderate range, I think the stakes are a little bit higher in terms of impairment and what we start to worry about for the longer term. And then I am more likely to recommend that a primary care physician or if they're seeing a psychiatrist start a medicine.

And then once symptoms are severe or symptoms have come back again and again as Dr. Arango was talking about, for some people there may be one episode, but for other kids there's a period of stability and then symptoms come back. Usually then we're looking at more subspecialty care that might involve the psychiatrist, a therapist, or even what we call a higher level of care. So maybe going to a partial hospitalization programming and being in intensive treatment for the daytime as if they were going to school, or of course, seeking out emergency care and hospital care if symptoms really are severe, particularly around self-harm and suicidality.

Dr. Christina Cwynar:

I really appreciate you differentiating out what levels of depression different types of providers can manage, because that's one of the goals of this podcast, is to better arm our colleagues and other specialties to help care for these individuals because access is such an issue. And hopefully by listening to not only this episode, but some of the subsequent episodes, they will be more empowered to do that and to also access some of the resources we're able to provide and some of the dosing parameters and some of the books we'll reference and all of those things that we're going to talk through in some of the episodes coming up this season. So, I think it'll be a very rich season, so I appreciate that. Are there any other thoughts for anybody sitting around the table today?

Dr. Joanna Quigley:

I do want to end on a hopeful note and say that there's a lot that we can do to help support our youth and help in a preventive mindset. So, when you're engaging with your families, even if the visit is not about a mental health concern, that checking in with kids and seeing how they're doing with their friends, with school is really important. We know that kids who experience a sense of more support and supervision from adults in their lives, and that does not have to be their parents, do better, they're less likely to use substances, they're more likely to feel capable and successful. And that ties into feelings of self-confidence and being able to manage the stressors that hit them in life. And I think that's a really rich gift to give the youth in your community, whether or not they're your kids or people you know in the neighborhood. But it is a community effort, I think at this point with the degree of crisis we're dealing with to help youth feel more empowered.

Dr. Alejandra Arango:

I think I would just like to add to what Dr. Quigley said right there. Is there is a lot of hope, there's a lot of points of intervention, and part of going back to screening, which we talked about earlier. We can do things when the screen is getting close to meeting the criteria. All of that is helpful information for places that we can intervene and both from a professional delivering services perspective.

But in some of my research work in the area of suicide prevention, my work really focuses on connectedness and how we can support one another and how, whether it's in the school setting or the community setting or the family setting, how building and strengthening some of those relationships is so critical for youth. And I think we've been recovering or adjusting, however we want to call it, after the pandemic, to the ways that we interact with one another and continuing to be really effortful and thoughtful about continuing to cultivate those relationships and connectedness with youth is so important. But I definitely agree that I think there's a lot of hope and a lot of things that we can do and that are being done.

Syma Khan:

Yeah, I think there's a lot of really exciting work being done, and I think we're understanding more, we're learning more, and I think we hope that everyone listening today feels a little more empowered, as Christina said, to support our youth through this because it's difficult and so many feel alone. And just that one caring individual can be really supportive and help build that trust that maybe at some point if they are struggling, they disclose that and we can get them to the resources that they need.

Dr. Christina Cwynar:

I love how we're ending this episode on a note of positivity and prevention. And I don't know why it brought me back to this thought, but even thinking about our littles, our five and six year olds, and some of the things that we're showing them and teaching them, and the question I get from my friends, my family, my colleagues at work, is how do I help prepare them for this world? And my answer is always, teach them how to identify their emotion. Teach them distress tolerance. Teach them different coping skills. Teach them to talk to you, teach them that you're a safe person, that nothing they say to you is going to elicit this really dramatic response. So when these really big scary things come up, it's okay. And they can come tell you.

So those are the things that we can start working with, even our three-year-olds on, and as parents, so as pediatricians, whoever we may be. So, thank you both for being here today and sharing your expertise. We highly appreciate you.

Dr. Alejandra Arango:

Thanks for having us.

Dr. Christina Cwynar:

And thank you to our audience for joining us this week. Nurses, social workers and physicians can claim CMEs and CUs at uofmhealth.org/breakingdownMentalhealth. You are able to do this anytime within three years of the initial air date. We hope you will join us next time.