The interplay between adolescent friendship quality and resilient functioning following childhood and adolescent adversity.

Background: Child and adolescent adversity ('CA') is a major predictor of mental health problems in adolescence and early adulthood. However, not all young people who have experienced CA develop psychopathology; their mental health functioning can be described as resilient. We previously found that resilient functioning in adolescence following CA is facilitated by adolescent friendships.However, during adolescence, friendships undergo significant change. It is unknown whether resilient functioning after CA fluctuates with these normative changes in friendship quality. Methods: We used Latent Change Score Modelling in a large sample of adolescents (i.e. the ROOTS cohort; N=1238) to examine whether and how emergent friendship quality and resilient functioning at ages 14 and 17 inter-relate and change together. Results: We found that friendships quality and resilient functioning had strong associations at age 14, although friendships at 14 did not predict higher resilient functioning at 17. Higher resilient functioning in 14-year-olds with a history of CA was associated with a positive change in friendships from age 14 to 17. Finally, improvements in friendship quality and resilient functioning went hand in hand, even when taking into account baseline levels of both, the change within friendship quality or resilient functioning over time, and the association between resilient functioning and change in friendship quality over time. Conclusions: We show that friendship quality and resilient functioning after CA inter-relate and change together between ages 14 and 17. Our results suggest that improving friendship quality or resilient functioning within this timeframe may benefit this vulnerable adolescent group, and this should be tested in future research.

Embracing the positive: an examination of how well resilience factors at age 14 can predict distress at age 17.

One-in-two people suffering from mental health problems develop such distress before or during adolescence. Research has shown that distress can predict itself well over time. Yet, little is known about how well resilience factors (RFs), i.e. those factors that decrease mental health problems, predict subsequent distress. Therefore, we investigated which RFs are the best indicators for subsequent distress and with what accuracy RFs predict subsequent distress. We examined three interpersonal (e.g. friendships) and seven intrapersonal RFs (e.g. self-esteem) and distress in 1130 adolescents, at age 14 and 17. We estimated the RFs and a continuous distress-index using factor analyses, and ordinal distress-classes using factor mixture models. We then examined how well age-14 RFs and age-14 distress predict age-17 distress, using stepwise linear regressions, relative importance analyses, as well as ordinal and linear prediction models. Low brooding, low negative and high positive self-esteem RFs were the most important indicators for age-17 distress. RFs and age-14 distress predicted age-17 distress similarly. The accuracy was acceptable for ordinal (low/moderate/high age-17 distress-classes: 62-64%), but low for linear models (37-41%). Crucially, the accuracy remained similar when only self-esteem and brooding RFs were used instead of all ten RFs (ordinal = 62%; linear = 37%); correctly predicting for about two-in-three adolescents whether they have low, moderate or high distress 3 years later. RFs, and particularly brooding and self-esteem, seem to predict subsequent distress similarly well as distress can predict itself. As assessing brooding and self-esteem can be strength-focussed and is time-efficient, those RFs may be promising for risk-detection and translational intervention research.

Cognitive behavioral therapy may have a rehabilitative, not normalizing, effect on functional connectivity in adolescent depression.

BACKGROUND: Whether the differences in brain structure and function, characteristic of adult major depressive disorder (MDD1), are present in adolescent MDD is still unclear, but it has been shown that cognitive behavioral therapy (CBT2) affects resting-state functional connectivity in both adult and adolescent MDD patients, with the claim that CBT has a normalizing effect on MDD-related functional disruption, but this has not been directly tested. METHODS: 128 adolescent MDD patients and 40 adolescent controls were enrolled in the study. We investigated pre-treatment differences in cortical thickness, white matter volume, and resting-state functional connectivity. We also investigated the longitudinal effects of CBT on resting-state functional connectivity, and the relationship between pre-treatment functional disruption and CBT-related changes to resting-state functional connectivity was assessed by the correlation of pre-treatment cross-sectional effects and longitudinal CBT-related effects across multiple brain regions. RESULTS: Patients had greater cortical thickness and white matter volume within fronto-limbic regions of the brain. Patients had greater pre-treatment resting-state functional connectivity within the default-mode, fronto-limbic, central-executive, and salience networks. CBT increased resting-state functional connectivity of the subgenual anterior cingulate and amygdala seeds with predominantly frontal regions. Regions showing the greatest pre-treatment functional disruption showed the weakest CBT-related changes. LIMITATIONS: For ethical reasons, there was no placebo group. CONCLUSIONS: Adolescent MDD is associated with structural and functional differences also seen in adult patients. CBT-related changes in resting-state functional connectivity do not appear to show a normalizing effect, but instead indicate rehabilitative effects on resting-state functional connectivity.

Unravelling the complex nature of resilience factors and their changes between early and later adolescence.

BACKGROUND: Childhood adversity (CA) is strongly associated with mental health problems. Resilience factors (RFs) reduce mental health problems following CA. Yet, knowledge on the nature of RFs is scarce. Therefore, we examined RF mean levels, RF interrelations, RF-distress pathways, and their changes between early (age 14) and later adolescence (age 17). METHODS: We studied 10 empirically supported RFs in adolescents with (CA+; n = 631) and without CA (CA-; n = 499), using network psychometrics. RESULTS: All inter-personal RFs (e.g. friendships) showed stable mean levels between age 14 and 17, and three of seven intra-personal RFs (e.g. distress tolerance) changed in a similar manner in the two groups. The CA+ group had lower RFs and higher distress at both ages. Thus, CA does not seem to inhibit RF changes, but to increase the risk of persistently lower RFs. At age 14, but not 17, the RF network of the CA+ group was less positively connected, suggesting that RFs are less likely to enhance each other than in the CA- group. Those findings underpin the notion that CA has a predominantly strong proximal effect. RF-distress pathways did not differ in strength between the CA+ and the CA- group, which suggests that RFs have a similarly protective strength in the two groups. Yet, as RFs are lower and distress is higher, RF-distress pathways may overall be less advantageous in the CA+ group. Most RF interrelations and RF-distress pathways were stable between age 14 and 17, which may help explain why exposure to CA is frequently found to have a lasting impact on mental health. CONCLUSIONS: Our findings not only shed light on the nature and changes of RFs between early and later adolescence, but also offer some accounts for why exposure to CA has stronger proximal effects and is often found to have a lasting impact on mental health.

A Network Model of Resilience Factors for Adolescents with and without Exposure to Childhood Adversity.

Resilience factors (RFs) help prevent mental health problems after childhood adversity (CA). RFs are known to be related, but it is currently unknown how their interrelations facilitate mental health. Here, we used network analysis to examine the interrelations between ten RFs in 14-year-old adolescents exposed ('CA'; n = 638) and not exposed to CA ('no-CA'; n = 501). We found that the degree to which RFs are assumed to enhance each other is higher in the no-CA compared to the CA group. Upon correction for general distress levels, the global RF connectivity also differed between the two groups. More specifically, in the no-CA network almost all RFs were positively interrelated and thus may enhance each other, whereas in the CA network some RFs were negatively interrelated and thus may hamper each other. Moreover, the CA group showed more direct connections between the RFs and current distress. Therefore, CA seems to influence how RFs relate to each other and to current distress, potentially leading to a dysfunctional RF system. Translational research could explore whether intervening on negative RF interrelations so that they turn positive and RFs can enhance each other, may alter 'RF-mental distress' relations, resulting in a lower risk for subsequent mental health problems.

Multiple markers of cortical morphology reveal evidence of supragranular thinning in schizophrenia.

In vivo structural neuroimaging can reliably identify changes to cortical morphology and its regional variation but cannot yet relate these changes to specific cortical layers. We propose, however, that by synthesizing principles of cortical organization, including relative contributions of different layers to sulcal and gyral thickness, regional patterns of variation in thickness of different layers across the cortical sheet and profiles of layer variation across functional hierarchies, it is possible to develop indirect morphological measures as markers of more specific cytoarchitectural changes. We developed four indirect measures sensitive to changes specifically occurring in supragranular cortical layers, and applied these to test the hypothesis that supragranular layers are disproportionately affected in schizophrenia. Our findings from the four different measures converge to indicate a predominance of supragranular thinning in schizophrenia, independent of medication and illness duration. We propose that these indirect measures offer novel ways of identifying layer-specific cortical changes, offering complementary in vivo observations to existing post-mortem studies.

Mood, anxiety and psychotic phenomena measure a common psychopathological factor.

BACKGROUND: Psychotic phenomena are common in the general population but are excluded from diagnostic criteria for mild to moderate depression and anxiety despite their co-occurrence and shared risk factors. We used item response theory modelling to examine whether the co-occurrence of depressive, anxiety and psychotic phenomena is best explained by: (1) a single underlying factor; (2) two separate, uncorrelated factors; (3) two separate yet linked factors; or (4) two separate domains along with an underlying 'common mental distress' (CMD) factor. We defined where, along any latent continuum, the psychopathological items contributed most information. METHOD: We performed a secondary analysis of cross-sectional, item-level information from measures of depression, anxiety and psychotic experiences in 6617 participants aged 13 years from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort and 977 participants aged 18 years from the ROOTS schools-based sample. We replicated results from one sample in the other and validated the latent factors against an earlier parental measure of mental state. RESULTS: In both cohorts depression, anxiety and psychotic items were best represented as a bi-factor model with a single, unitary CMD factor on which psychotic items conveyed information about the more severe end (model 4); residual variation remained for psychotic items. The CMD factor was significantly associated with the prior parental measure. CONCLUSIONS: Psychotic phenomena co-occur with depression and anxiety in teenagers and may be a marker of severity in a single, unitary dimension of CMD. Psychotic phenomena should be routinely included in epidemiological assessments of psychiatric morbidity, otherwise the most severe symptomatology remains unmeasured.

General distress, hopelessness-suicidal ideation and worrying in adolescence: concurrent and predictive validity of a symptom-level bifactor model for clinical diagnoses.

BACKGROUND: Clinical disorders often share common symptoms and aetiological factors. Bifactor models acknowledge the role of an underlying general distress component and more specific sub-domains of psychopathology which specify the unique components of disorders over and above a general factor. METHODS: A bifactor model jointly calibrated data on subjective distress from The Mood and Feelings Questionnaire and the Revised Children's Manifest Anxiety Scale. The bifactor model encompassed a general distress factor, and specific factors for (a) hopelessness-suicidal ideation, (b) generalised worrying and (c) restlessness-fatigue at age 14 which were related to lifetime clinical diagnoses established by interviews at ages 14 (concurrent validity) and current diagnoses at 17 years (predictive validity) in a British population sample of 1159 adolescents. RESULTS: Diagnostic interviews confirmed the validity of a symptom-level bifactor model. The underlying general distress factor was a powerful but non-specific predictor of affective, anxiety and behaviour disorders. The specific factors for hopelessness-suicidal ideation and generalised worrying contributed to predictive specificity. Hopelessness-suicidal ideation predicted concurrent and future affective disorder; generalised worrying predicted concurrent and future anxiety, specifically concurrent generalised anxiety disorders. Generalised worrying was negatively associated with behaviour disorders. LIMITATIONS: The analyses of gender differences and the prediction of specific disorders was limited due to a low frequency of disorders other than depression. CONCLUSIONS: The bifactor model was able to differentiate concurrent and predict future clinical diagnoses. This can inform the development of targeted as well as non-specific interventions for prevention and treatment of different disorders.

A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial.

OBJECTIVES: To determine if, in the short term, depressed adolescents attending routine NHS Child and Adolescent Mental Health Services (CAMHS), and receiving ongoing active clinical care, treatment with selective serotonin reuptake inhibitors (SSRIs) plus cognitive behaviour therapy (CBT) compared with SSRI alone, results in better healthcare outcomes. DESIGN: A pragmatic randomised controlled trial (RCT) was conducted on depressed adolescents attending CAMHS who had not responded to a psychosocial brief initial intervention (BII) prior to randomisation. SETTING: Six English CAMHS participated in the study. PARTICIPANTS: A total of 208 patients aged between 11 and 17 years were recruited and randomised. INTERVENTIONS: All participants received active routine clinical care in a CAMHS outpatient setting and an SSRI and half were offered CBT. MAIN OUTCOME MEASURES: The duration of the trial was a 12-week treatment phase, followed by a 16-week maintenance phase. Follow-up assessments were at 6, 12 and 28 weeks. The primary outcome measure was the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Secondary outcome measures were self-report depressive symptoms, interviewer-rated depressive signs and symptoms, interviewer-rated psychosocial impairment and clinical global impression of response to treatment. Information on resource use was collected in interview at baseline and at the 12- and 28-week follow-up assessments using the Child and Adolescent Service Use Schedule (CA-SUS). RESULTS: Of the 208 patients randomised, 200 (96%) completed the trial to the primary end-point at 12 weeks. By the 28-week follow-up, 174 (84%) participants were re-evaluated. Overall, 193 (93%) participants had been assessed at one or more time points. Clinical characteristics indicated that the trial was conducted on a severely depressed group. There was significant recovery at all time points in both arms. The findings demonstrated no difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point. This lack of difference held when baseline and treatment characteristics where taken into account (age, sex, severity, co-morbid characteristics, quality and quantity of CBT treatment, number of clinic attendances). The SSRI + CBT group was somewhat more expensive over the 28 weeks than the SSRI-only group (p=0.057) and no more cost-effective. Over the trial period there was on average a decrease in suicidal thoughts and self-harm compared with levels recorded at baseline. There was no significant increase in disinhibition, irritability and violence compared with levels at baseline. Around 20% (n=40) of patients in the trial were non-responders. Of these, 17 (43%) showed no improvement by 28 weeks and 23 (57%) were considered minimally (n=10) or moderately to severely worse (n=13). CONCLUSIONS: For moderately to severely depressed adolescents who are non-responsive to a BII, the addition of CBT to fluoxetine plus routine clinical care does not improve outcome or confer protective effects against adverse events and is not cost-effective. SSRIs (mostly fluoxetine) are not likely to result in harmful adverse effects. The findings are broadly consistent with existing guidelines on the treatment of moderate to severe depression. Modification is advised for those presenting with moderate (6-8 symptoms) to severe depressions (>8 symptoms) and in those with either overt suicidal risk and/or high levels of personal impairment. In such cases, the time allowed for response to psychosocial interventions should be no more than 2-4 weeks, after which fluoxetine should be prescribed. Further research should focus on evaluating the efficacy of specific psychological treatments against brief psychological intervention, determining the characteristics of patients with severe depression who are non-responsive to fluoxetine, relapse prevention in severe depression and improving tools for determining treatment responders and non-responders.

Do corticosteroids damage the brain?

Corticosteroids are an essential component of the body's homeostatic system. In common with other such systems, this implies that corticosteroid levels in blood and, more importantly, in the tissues remain within an optimal range. It also implies that this range may vary according to circumstance. Lack of corticosteroids, such as untreated Addison's disease, can be fatal in humans. In this review, we are principally concerned with excess or disturbed patterns of circulating corticosteroids in the longer or shorter term, and the effects they have on the brain.

Self-devaluative dysphoric experience and the prediction of persistent first-episode major depressive disorder in adolescents.

BACKGROUND: The quality of subjective experience of dysphoria may predict persistence of depression, independently of severity. This is tested in a clinic sample of adolescents with first episode of major depression using the Depressed States Checklist adapted for adolescents. METHOD: Ninety-four adolescents with DSM-IV major depressive disorder (MDD) were followed up at 12 months. Self-devaluative components of dysphoric experience, ruminative style, over-general autobiographical memory, and self-reported and observer-rated measures of depression severity were assessed at presentation and evaluated as predictors of persistent MDD. RESULTS: Persistent MDD was predicted by the independent additive effects of the higher self-devaluative component of dysphoria, lower general intelligence and greater observer-rated severity of depression at presentation. Neither self-reported depression score, overgeneral memory retrieval nor ruminative style contributed. CONCLUSIONS: High levels of self-devaluative dysphoric experience increase the liability for persistence of first-episode MDD. Other affective-cognitive components also contribute. The adolescent version of the Depressed States Checklist is a useful brief measure of cognitive vulnerability for persistence in currently depressed young people.

Effects of induced rumination and distraction on mood and overgeneral autobiographical memory in adolescent Major Depressive Disorder and controls.

BACKGROUND: In adults there is evidence that the affective-cognitive processes of rumination and overgeneral autobiographical memory retrieval may play a part in maintaining depression. This study investigated the effects of induced rumination as compared to distraction on mood and categoric overgeneral memory in adolescents with first episode Major Depressive Disorder (MDD), and the specificity of any effects to MDD. METHOD: Three subject groups; adolescents with first episode MDD (N = 75), non-depressed psychiatric participants (N = 26) and community controls (N = 33) were recruited. An experimental design was used, with repeated measures of 'in the moment' depressed mood and categoric overgeneral memory before and after rumination and distraction, induced on separate occasions and counterbalanced in order across participants. RESULTS: In adolescents with MDD, induced rumination as compared to distraction differentially increased depressed mood. There were no significant differences in this effect between full current MDD participants and those in partial remission. This differential effect was also seen in community controls but was absent in non-MDD psychiatric participants. In addition, rumination as compared to distraction increased overgeneral memories to negative cues in MDD participants, but this increase was not significantly related to mood change, and was specific to MDD, being absent in non-MDD psychiatric and community control groups. CONCLUSIONS: Experimentally induced rumination as compared to distraction increases depressed mood and negative categoric memories in adolescents with first episode MDD. These results suggest that rumination has a deleterious effect on mood and memory retrieval processes in adolescents with first episode MDD. Increased negative overgeneral memories with rumination may be a process of particular importance for adolescents with MDD rather than psychiatric disorder in general. The findings imply that strategies to interrupt ruminative processes may be helpful in minimising persistence of first episode MDD in adolescence.

The aetiology of specific language impairment: no evidence of a role for obstetric complications.

The role of obstetric complications (OC's) in Specific Language Impairment (SLI) has been investigated, but the relationship remains unclear. This study investigates the association between SLI and OC's in a sample of 194 children, participants in a family study of SLI. Initial analyses utilising a traditional case-control approach found no evidence of an association. The effect of changing the case criteria was explored, but the finding of no association remained. The relationship between OC's and various language measures was also investigated using continuous data analytic techniques. This supported the findings of the case control analysis of no association. Previous reports have suggested a specific role for either hypertension or toxaemia in pregnancy. This study found no evidence for an association between these complications of pregnancy and SLI. This study found no evidence to support an aetiological role of OC's in SLI.

Psychoendocrine antecedents of persistent first-episode major depression in adolescents: a community-based longitudinal enquiry.

BACKGROUND: This longitudinal study investigated whether patterns of cortisol and DHEA that precede the onset of an episode of major depression influence time to recovery in a community ascertained sample of adolescents meeting DSM-IV criteria for major depression. METHOD: Sixty adolescents aged 12 to 16 at high risk for psychiatric disorders were followed for 24 months. At 12 months, 30 had experienced an episode of major depression and 30 had not. The second follow-up repeated the psychiatric evaluations with all participants completing the Kiddie-SADS Schedule for Schizophrenia and Affective Disorders. Hormone characteristics and self-reports completed at entry (the Mood and Feelings questionnaire and the Ruminations scale) together with intervening undesirable life events in the 12 months prior to onset, were used to determine the best pattern of psychosocial and endocrine features to predict persistent major depression. RESULTS: Compared to the never depressed (N = 30) and remitted adolescents (N = 19), persistently depressed cases (N = 11) had a raised morning cortisol/DHEA ratio at entry. Only persistent cases had higher levels of self-reported depressive symptoms and ruminations at entry compared to never depressed. There was no difference in exposure to undesirable life events before onset of disorder between remitted and persistent groups. Logistic regression techniques showed that only the cortisol/DHEA ratio predicted persistence. CONCLUSIONS: In community adolescents at high risk for psychiatric disorder persistent major depression may be distinguished from sporadic forms by the 08.00 h salivary cortisol/DHEA ratio prior to onset.

Categoric overgeneral autobiographical memory in adolescents with major depressive disorder.

BACKGROUND: Categoric, overgeneral autobiographical memory is more common in depressed adults than controls and predicts persistence of depression. This cross-sectional study investigated whether, compared with non-depressed psychiatric cases and community controls, first episode major depressive disorder (MDD) in adolescents is associated with categoric overgeneral memory retrieval. METHODS: Ninety-six clinically referred adolescents (aged 12-17 years) with MDD, 26 non-depressed psychiatric cases and a sample of 33 community controls were recruited. All subjects were assessed using the Kiddie-Schedule for Schizophrenia and Affective Disorders, and completed Williams' cued Autobiographical Memory Test and the Mood and Feelings Questionnaire. Hamilton Depression Rating Scales were completed with MDD subjects, as an index of depression severity. RESULTS: Adolescents with current first episode MDD retrieved more categoric overgeneral memories than controls, but not than non-depressed psychiatric cases. Adolescents in full remission from a recent episode of MDD retrieved more categoric memories to positive cues than controls. Categoric memory in MDD was related to observer-rated and self-reported severity, but not to the pattern of co-morbid diagnoses. There were negative correlations between IQ and categoric memories in both clinical cases and controls. A positive correlation between categoric memory to negative cues and self-reported depressive symptoms was found in clinical cases (but not controls). CONCLUSIONS: In adolescents, increased categoric overgeneral memory is associated with, but not specific to first episode MDD. Positive categoric memories are also increased in fully remitted MDD as compared to controls.

Family functioning in adolescents at high and low risk for major depressive disorder.

Families of two subgroups of adolescents in the community, at high and low risk for major depressive disorder, were compared on the McMaster Family Assessment Device (FAD) and the General Health Questionnaire (GHQ). Families of high-risk adolescents who became depressed by follow-up at one year were compared with other families of high-risk subjects. The only significant difference on FAD ratings for high- and low-risk groups was on the sub-scale Roles as reported by mothers. FAD ratings showed that, compared with mothers, fathers of high-risk adolescents held significantly worse views of their families' functioning on the sub-scales Problem Solving, Affective Responsiveness and Behaviour Control. There were no such differences between low-risk parents. Both mothers and fathers of high-risk adolescents reported their own mental health as significantly poorer than mothers and fathers of low-risks. The mental health of mothers in the high-risk group only was significantly associated with their FAD ratings. Adolescents rated their families as significantly worse on the FAD than their parents and the lower their mood and self-esteem, the worse they rated their families on the FAD. Subsequent MDD in adolescents by follow-up at one year was not associated with the FAD scores of any family member, nor with either parent's mental health.

Possible role of cortisol and dehydroepiandrosterone in human development and psychopathology.

BACKGROUND: The characteristics of adrenal hormone secretion change markedly during infancy. Disturbances in basal levels may precipitate psychological dysfunction and are associated with psychopathology in young people. AIMS: To relate three aspects of behavioural endocrinology: developmental changes in cortisol and dehydroepiandrosterone (DHEA), the role of these hormones in the psychopathology of young people, and the action of these steroids in the brain. METHOD: A selective review from the human developmental, psychiatric and neurosciences literature. RESULTS: There are developmentally mediated changes in brain sensitivity following excess exposure to cortisol. This may result in impairments of mental and behavioural function. DHEA and gonadal steroids may modulate the actions of cortisol. CONCLUSIONS: Steroid hormones contribute to shaping behavioural function during early development and act as risk factors for psychopathology.

Psychosocial and endocrine features of chronic first-episode major depression in 8-16 year olds.

BACKGROUND: Psychoendocrine processes may have a role in explaining individual differences in the outcome of major depression in 8-16-year-old school children. METHODS: Salivary cortisol and dehydroepiandrosterone (DHEA) levels at 8:00 AM and 8:00 PM, life events, and comorbidity were assessed at presentation, 36, and 72 weeks in 47 (60%) of 78 clinically referred subjects with a first episode of major depression. Comparisons were made between chronic and nonchronic major depression. RESULTS: Chronic depression was characterized by being older, cortisol hypersecretion at 8:00 PM at all three assessments, increasing depression-dependent life events over the follow-up period, and comorbid obsessive-compulsive disorder (OCD) at presentation and at 36 weeks. Chronicity may be best predicted by increasing depression-dependent events over the 72-week period. Such events are more likely in cases with evening cortisol hypersecretion at entry and persistent OCD. Variations in DHEA levels were not associated with chronicity or increasing life events. CONCLUSIONS: During adolescence, but not childhood, the persistence of major depression may occur through an increase of risk for further and particular types of depression-dependent undesirable life events (personal disappointments and/or dangers to the self), that are more likely in those subjects with persisting cortisol hypersecretion and unresolved comorbid OCD.

Recent life events, cortisol, dehydroepiandrosterone and the onset of major depression in high-risk adolescents.

BACKGROUND: It is not clear whether cortisol or dehydroepiandrosterone (DHEA) hypersecretion increases the risk for major depression in the presence of undesirable life events. AIMS: To determine whether there is a specific pattern of psychoendocrine factors that predicts the onset of major depressive disorder. METHOD: 180 adolescents (73 boys, 107 girls) at high risk for psychopathology were assessed for cortisol, DHEA, depressive symptoms, life events and psychiatric disorder at entry and 12 months later. RESULTS: Major depression was predicted for both genders by the additive effects of: higher depressive symptoms; personal disappointments and losses only in the month before onset; one or more daily levels of cortisol at 08.00 h or DHEA at 20.00 h greater than the 80th percentile of the daily mean. CONCLUSIONS: A subgroup of adolescents may carry a physiological risk for major depression which may be either of genetic and/or earlier psychosocial origin.

Clinical guidelines for depressive disorders in childhood and adolescence.

Major depressive and dysthymic disorders are recurrent and sometimes persistent unipolar mood disorders, which often present in childhood and adolescence. Depressive episodes may increase in severity and duration with recurrence and are associated with substantial morbidity and risk of suicide. The role of child and adolescent mental health services in early intervention and management is thus of major importance. This paper draws together current research evidence and common clinical practice, in guidelines for the specialist management of depressive disorders in childhood and adolescence. Both psychotherapy and pharmacotherapy have been found to be beneficial for the acute treatment of children and adolescents with depressive disorders. Based on current evidence, psychotherapy may be the first treatment for most depressed youngsters, but antidepressants should be considered for those with severe depression. All patients need continuation therapy, and some will need maintenance treatment. Evidence supporting the efficacy of psychological and psychopharmacological treatments are reviewed. An integration of approaches is suggested as a guideline for treatment planning.