Depressed Adolescents Grown Up
abstract & commentary
Synopsis: Adolescents who experience an episode of major depression are at markedly increased risk for subsequent episodes of depression, suicide attempts, and impaired functioning. Early identification and treatment is warranted.
Source: Weissman MM, et al. Depressed adolescents grown up. JAMA 1999;281(18):1707-1713.
It is increasingly apparent that depression is often a recurrent disorder. This prospective, case-controlled study evaluated the subsequent risk of 73 subjects with adolescent-onset major depression (MDD) after 10-15 years of follow-up, compared to 37 control subjects without major depression at the time of initial evaluation. The depressed adolescents were identified at Columbia Presbyterian Hospital from 1977 to 1985. The diagnosis of depression was confirmed on two separate interviews, separated by two weeks. Subjects were not included in the original sample if they had been taking medication that could produce depressive symptoms, or had significant medical problems or other psychiatric disorders. Healthy controls were recruited concurrently via advertisement. Interviewers who were blind to the initial diagnosis collected follow-up data. Collateral information was obtained from an adult who was knowledgeable about the subjects functioning during the follow-up period; in most cases this was the subject’s parent. Copies of medical records were obtained and used to supplement the interview data. Data analysis was appropriate and controlled for covariate and potential confounds. At follow-up there were no significant demographic differences between the two groups. Subjects with adolescent-onset MDD had a significantly increased risk of MDD compared to healthy controls (> 2-fold), but not for other psychiatric disorders. There were no gender differences in the risk of subsequent MDD. At the end of the observation period, only 37% of subjects with adolescent-onset MDD survived without an episode of MDD, compared to 69% of the control subjects in the some period (P < 0.05). Seven suicides occurred in the adolescent-onset MDD subjects. In addition, 26.1% of the adolescent-onset MDD subjects and 5.4% of the controls made a first suicide attempt during the follow-up period. In total, 50.6% of the adolescent- onset MDD subjects made a suicide attempt over their lifetime to follow-up and 22% had made multiple attempts. Subjects with adolescent-onset MDD also had higher rates of medical hospitalizations (P = 0.008). In summary, adolescent-onset MDD is associated with continuity and specificity of MDD into adulthood with high rates of suicide attempts and psychosocial impairment.
Comment by Lauren B. Marangell, MD
Adolescent MDD was found to have a poor outcome and strong predictive value for subsequent episodes of MDD, but not other psychiatric disorders. These data are particularly striking given the methodological rigor of the study by a well-respected group of investigators. Although most depressed adolescents will not seek psychiatric treatment, there is tremendous opportunity for primary care practitioners to intervene when there is the suspicion of depression. As a reminder, physical symptoms without etiology, increased irritability, and loss of interest in usual activities should raise suspicion of adolescent depression. On a more optimistic note, Weissman and colleagues point out that although the subjects received state-of-the-art treatment for the time, currently effective treatments were not available at the time. Specifically, controlled trials have failed to demonstrate efficacy for the tricyclic antidepressants in adolescent depression. Treatments with demonstrated efficacy in clinical trials that include adolescent depression are the selective serotonin reuptake inhibitors1 and newer time-limited therapies developed for adolescents.
Reference
1. Emslie GJ, et al. Fluoxetine treatment of depressed children and adolescents. Arch Gen Psychiatry 1997; 54:1031-1037.
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