Atypical symptoms of depression in a sample of depressed child and adolescent outpatients.

OBJECTIVE: To examine the presence of symptoms of atypical depression among children and adolescents with a major depressive disorder (MDD). METHOD: One thousand forty-six youths (aged 6-19 years) meeting DSM-III-R criteria for MDD were included in the study. All subjects had presented at an outpatient clinic seeking treatment and were identified as having MDD via clinical interviews using the semistructured Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode (K-SADS-P) with the youngster themselves and a parent/guardian. A diagnosis of atypical depression was derived from the symptoms of depression assessed in the K-SADS-P and required the presence of mood reactivity and at least one the following symptoms: hypersomnia, increased appetite, weight gain, or psychomotor retardation (substituted for leaden paralysis). RESULTS: One hundred sixty-two (15.5%) of the depressed youths met criteria for atypical depression. The symptoms of atypical depression were found to correlate marginally, and the diagnosis of atypical depression had marginal construct validity for both children and adolescents. CONCLUSIONS: The findings from this large sample of depressed children and adolescents suggest that atypical features of depression occur in this age group. However, the diagnosis of atypical depression appears to have only marginal construct validity for both children and adolescents.

Randomized, controlled trial of amitriptyline versus placebo for adolescents with "treatment-resistant" major depression.

OBJECTIVE: To assess the response to a serotonergic/noradrenergic tricyclic antidepressant, amitriptyline (AMI), in a group of adolescents with treatment-resistant major depressive disorder (MDD). METHOD: Twenty-seven depressed adolescents admitted to a state hospital underwent a 10-week randomized, controlled trial with a flexible dose of AMI or placebo. RESULTS: There were no differences between patients taking AMI (n = 13) and placebo (n = 14). Both treatment groups showed approximately 70% to 80% improvement on the clinical outcome measurements, and 65% to 70% showed functional improvement. At the end of the protocol, 30% of patients still fulfilled criteria for MDD and had impaired functioning. Patients taking AMI experienced significantly more dry mouth and tachycardia. The final AMI dose was 173.1 mg/day +/- 56.3 mg/day; blood levels were 226.2 ng/mL +/- 80.8 ng/mL. CONCLUSIONS: No significant differences were found between AMI and placebo, in part because of the high placebo response rate. Although both treatment groups showed substantial response, at the end of treatment a substantial proportion of patients still had MDD of subsyndromal symptoms of depression. This and other studies of tricyclic antidepressants question the use of this medication as first-line treatment for youths with MDD.

The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics.

OBJECTIVE: To develop a reliable and valid child and parent self-report instrument to screen children with anxiety disorders. METHOD: An 85-item questionnaire was administered to 341 outpatient children and adolescents and 300 parents. Utilizing item analyses and factor analyses, the original scale was reduced to 38 items. A subsample of children (n = 88) and parents (n = 86) was retested an average of 5 weeks (4 days to 15 weeks after the initial screening. RESULTS: The child and parent Screen for Child Anxiety Related Emotional Disorders (SCARED) both yielded five factors: somatic/panic, general anxiety, separation anxiety, social phobia For the total score and each of the five factors, both the child and parent SCARED demonstrated good internal consistency (alpha = .74 to .93), test-retest reliability (intraclass correlation coefficients = .70 to .90), discriminative validity (both between anxiety and other disorders and within anxiety disorders), and moderate parent-child agreement (r = .20 to .47, p < .001, all correlations). CONCLUSIONS: The SCARED shows promise as a screening instrument for anxiety disorders. Future studies using the SCARED in community samples are indicated.

Fluoxetine for childhood anxiety disorders.

OBJECTIVE: The objective of this open study was to determine the efficacy and safety of fluoxetine for the treatment of children and adolescents with anxiety disorders. METHOD: Twenty-one patients with overanxious disorders, social phobia, or separation anxiety disorder, who were unresponsive to previous psychopharmacological and psychotherapeutic interventions, were treated openly with fluoxetine for up to 10 months. Patients with lifetime histories of obsessive-compulsive disorder (OCD) or panic disorder, or with current major depression, were excluded. Beneficial and adverse effects of fluoxetine were ascertained using the improvement and severity subscales of the Clinical Global Impression Scale (CGIS) in two ways: (1) independent chart reviews by two child psychiatrists and (2) prospective assessments by the treating nurses and the patients' mothers. RESULTS: Eighty-one percent (n = 17) of patients showed moderate to marked improvement in anxiety symptoms. The severity of anxiety as measured by the CGIS was also significantly reduced from marked to mild (effect size: 2.3). There were no significant side effects. CONCLUSIONS: These results suggest that fluoxetine may be an effective and safe treatment for nondepressed children and adolescents with anxiety disorders other than OCD and panic disorder. Future investigations using double-blind, placebo-controlled methodologies are warranted.

Familial risk factors for adolescent suicide: a case-control study.

Sixty-seven adolescent suicide victims and 67 demographically matched living controls were compared as to family constellation, familial stressors and familial loading for psychopathology. Suicide victims were less likely to have lived with both biological parents, were more likely to be exposed to stressors such as parent-child discord, physical abuse and residential instability and showed greater familial loading for depression and substance abuse. Multivariate analyses showed that family history of both depression and substance abuse and lifetime history of parent-child discord were most closely associated with adolescent suicide. Children who are the offspring of parents with depression or substance abuse should be psychiatrically screened. Family interventions to decrease discord may also be helpful in decreasing the risk of adolescent suicide.

Risk factors for completed suicide among adolescents with a lifetime history of substance abuse: a case-control study.

The risk factors for suicide in adolescents with substance abuse were assessed by comparing 23 adolescent suicide victims and 12 community controls with a lifetime history of definite or probable DSM-III substance abuse. Suicide victims were more likely than controls to show the following risk factors: active substance abuse, comorbid major depression, suicidal ideation within the past week, family history of depression and substance abuse, legal problems and presence of a handgun in the home. Recommendations for the identification and prevention of suicide among substance-abusing youth on the basis of these findings are presented.

Bereavement or depression? The impact of the loss of a friend to suicide.

OBJECTIVE: To determine whether the depressive reactions experienced by youth exposed to suicide were uncomplicated bereavement or bona fide major depression. METHOD: In a sample of 146 friends and acquaintances of 26 adolescent suicide victims, 43 (29%) developed a depressive episode subsequent to exposure to suicide, 18 were depressed before exposure, and 85 were never depressed. The three groups were compared. RESULTS: Those who became depressed after exposure were similar to those who were depressed before exposure. Both depressed groups differed from the nondepressed exposed group with respect to functional impairment, depressive symptom pattern and severity, convergent validity with other measures of depression, personal and family history of depression, and stressful life events. Previous depressives showed greater comorbidity with nonaffective disorders than those who became depressed after exposure. Those who became depressed after exposure compared with both the previous and nondepressive had a closer relationship with the suicide victims, showed more severe grief, and showed more intense exposure to the suicide. CONCLUSIONS: Depressive reactions occurring after exposure to suicide appear to be bona fide major depression, occurring as a complication of bereavement. Youth exposed to suicide should be carefully screened and followed up. Should a symptomatic picture of depression and functional impairment ensue, such exposed youth should be treated accordingly for a major depressive episode.

Adolescent witnesses to a peer suicide.

OBJECTIVE: This case-control study attempts to evaluate the psychological impact of witnessing a suicide on high school students. METHOD: Twenty-eight high school students witnessed a firearms suicide and the serious injury of another student while riding a school bus. They were assessed 2 months after the event, and their responses were compared with 28 demographically similar adolescents from another community who had not been exposed to suicide. RESULTS: The exposed students, when compared with the controls, had higher rates of new-onset anxiety disorder and a trend for increased rates of new-onset post-traumatic stress disorder (PTSD). Within the exposed group, measures of the closeness of the relationship to both the suicide victim and the student who was injured were correlated with the severity of PTSD symptomatology. Within the exposed group, other factors that predisposed to new-onset disorder included family history of affective illness, family history of suicide attempt, and stressful life events occurring in the year before exposure. CONCLUSIONS: In combination with the extant literature, this study demonstrates that adolescents who witness a traumatic suicidal death are at risk for the development of psychopathology, specifically, anxiety disorders and PTSD.

Psychiatric impact of the loss of an adolescent sibling to suicide.

Twenty-five adolescent siblings of 20 adolescent suicide victims were psychiatrically assessed 6 months after the suicide, and compared to 25 demographically matched controls. Siblings were much more likely to show a new-onset major depression subsequent to exposure to suicide. New-onset depression was associated with previous psychiatric disorder, family history of any psychiatric disorder, and family history of major depression. Mothers of suicide victims, compared to the mothers of controls, were also more likely to be depressed 6 months after the suicide of their child. The development of a family-based intervention for families of adolescent suicides is recommended.

Psychiatric sequelae to the loss of an adolescent peer to suicide.

OBJECTIVE: This study was designed to learn whether friends and acquaintances of suicide victims were at increased risk for depression, post-traumatic stress disorder, and suicidal behavior after exposure to suicide. METHOD: The social networks of 26 adolescent suicide victims, consisting of 146 adolescents, were interviewed 7 months after the death of the suicide victim and compared with 146 matched, unexposed controls. RESULTS: The rates of these disorders that had onset after exposure were elevated in the exposed group vs. controls: major depression, post-traumatic stress disorder, suicidal ideation with a plan or an attempt, but not suicidal attempts. Almost all of those exposed youth who developed new-onset suicidality did so in the context of a new-onset depressive episode. The majority of these new-onset depressive disorders began within 1 month of exposure. CONCLUSION: Postvention programs not only should focus on the prevention of imitation of suicidal behavior, but also should provide longer term follow-up for potentially bereaved and depressed youth exposed to suicide.

Psychiatric risk factors for adolescent suicide: a case-control study.

OBJECTIVE: The objective of this study was to determine the psychiatric risk factors for adolescent suicide. METHOD: Sixty-seven adolescent suicide victims were compared with 67 demographically matched community controls. Psychiatric disorder was assessed in suicide victims using a psychological autopsy protocol and in controls using similar semistructured psychiatric interviews. Risk factors were quantified by use of the odds ratio (OR), that is, the relative frequency of the occurrence of a given condition in the suicides compared with the controls. RESULTS: The most significant psychiatric risk factors associated with adolescent suicide were major depression (OR = 27.0), bipolar mixed state (OR = 9.0), substance abuse (OR = 8.5), and conduct disorder (OR = 6.0). Substance abuse was a more significant risk factor when comorbid with affective illness than when alone (OR = 17.0 versus 3.3). The majority of depressed suicide victims had a primary affective disorder (82%). A significant minority (31%) of depressed suicide victims had been depressed less than 3 months. Previous suicide attempts, suicidal ideation, and homicidal ideation also were associated with adolescent suicide. CONCLUSIONS: The development of effective treatments for youth who fit the above-noted risk profiles should be given high priority.

The validity of diagnoses obtained through the psychological autopsy procedure in adolescent suicide victims: use of family history.

A test of validity of the psychiatric diagnoses obtained by the psychological autopsy procedure is described in a consecutive series of 67 adolescent suicide victims. Family history of mental illness in first-degree relatives of subjects was obtained blind to subject diagnosis using the family history method. It was hypothesized that subjects with a given diagnosis, compared with subjects without this diagnosis, would show an increased rate of this disorder among first-degree relatives. This hypothesis was supported insofar as specific associations between subject diagnosis and familial rates of illness were demonstrated for major depression, bipolar illness, conduct and antisocial disorder and substance abuse. These results provide further support for the validity of diagnoses obtained through the psychological autopsy procedure.

Stressful life events, psychopathology, and adolescent suicide: a case control study.

The relationship between stressful life events and adolescent suicide was assessed in 67 adolescent suicide victims and 67 matched community controls. In the year before death, suicide completers were more likely to have experienced: (1) interpersonal conflict with parents and with boy/girlfriends, (2) disruption of a romantic attachment, (3) legal or disciplinary problems. Legal or disciplinary problems were more commonly associated with suicide in conduct and substance abuse disordered youth. Interpersonal loss was more commonly associated with suicide in substance abuse as well. Even after controlling for psychopathology, legal and disciplinary problems in the past year were associated with an increased risk of suicide.

Psychiatric effects of exposure to suicide among the friends and acquaintances of adolescent suicide victims.

The friends and acquaintances (N = 58) of 10 adolescent suicide victims were interviewed 6 months after the death of the victims, and the rates of psychiatric disorders that had onset after the death were compared with the 6-month incidence of psychopathology in 58 demographically and psychiatrically matched unexposed controls. The exposed group showed higher rates of any new onset major depressive disorder, but the rate of incident suicide attempts was the same in both groups. The median onset of incident depression among the exposed group was within the first month after exposure, and the majority of those exposed youth with incident depression were still depressed at interview 6 months after the death. Adolescent friends and acquaintances of suicide victims experience considerable psychiatric morbidity subsequent to exposure to suicide, most consistent with pathological grief.