Depression and Suicide in Adolescents
Monica Sifuentes, MD, and Robin Steinberg-Epstein, MD
A 15-year-old girl is brought to your office by her mother with the chief report of easy fatigability. The mother is concerned because her daughter is always tired, although several other physicians have told her that the girl is healthy. The adolescent, who states no complaints or concerns, appears quite shy. She is currently in the 10th grade, likes school, receives average grades, and speaks English and Spanish. The mother, a single parent, moved to the United States from El Salvador approximately 2 years ago with her 2 daughters. Currently, they are living with relatives in a two-bedroom apartment. The mother is employed as a housekeeper, and the patient and her sister help their mother clean homes on weekends. During the week they make dinner for the rest of the family as a means of contributing to the rent. When you speak to the girl alone, she acknowledges she has a few friends at school and adamantly denies any drug, alcohol, or tobacco use. She has never been sexually active and reports no history of sexual or physical abuse. She scores 11 on the 9-item Patient Health Questionnaire. The physical examination is entirely normal, although the girl’s affect appears somewhat flat.
1. What is the significance of nonspecific symptoms, such as fatigue, during adolescence?
2. What factors contribute to depression in the adolescent?
3. What are the classic signs and symptoms of depression in the adolescent?
4. What are some important points to cover in the history when interviewing the adolescent with suspected depression?
5. What is the purpose of the depression/suicide screening tool (eg, Patient Health Questionnaire-9)? How should the results be interpreted and used?
6. How is the risk of suicide assessed in the adolescent patient?
7. How should suicidal behavior (ie, suicide attempts) be managed in the adolescent?
The number of people in the United States with mental health concerns, including depression and suicidality, far surpasses the number of mental health specialists. For this reason, the American Academy of Pediatrics recommends that primary care physicians take an active role in the identification and early management of uncomplicated mental health concerns in children and adolescents. Furthermore, the importance of primary care physicians in this arena is emphasized by research findings. Patients who ultimately die by suicide visit primary care physicians more than twice as often as mental health clinicians in the months leading up to their death. A review of studies analyzing this clinical scenario estimated 45% of those who died by suicide saw their primary care physician in the month before their death, whereas only 20% saw a mental health professional in the preceding month. Women and older patients are more likely to have sought care in the month before their suicide compared with men and younger patients. Those who practice general medicine (ie, internists, pediatricians, family physicians) write most of the antidepressant prescriptions in the United States.
Depression and suicidality are common in the pediatric and adolescent population. Thus, it is important to remain cognizant of their clinical presentation and to diligently screen and probe for their presence.
Depression is among the multiple risk factors that predispose adolescents to suicide. Not all teenagers who attempt suicide are depressed, however; conversely, not all depressed adolescents attempt suicide. This distinction is important to keep in mind when evaluating any adolescent for depression or suicidal behavior. Early identification of risk factors in the susceptible adolescent along with early intervention for those with depressive symptoms will, it is hoped, benefit the teenager at risk for suicide and allow the primary care pediatrician to provide first-line intervention for the adolescent patient experiencing emotional distress.
The exact prevalence of depression in adolescents is difficult to determine because depression is often underreported. It is considered 1 of the main psychiatric conditions affecting children and adolescents, however, along with anxiety. Depressive symptoms have been reported in as many as 50% of girls and 40% of boys in the 14- to 15-year age group. The overall prevalence of depression as an illness is approximately 5%; mild depression is reported in 13% to 28% of teenagers, moderate depression in 7%, and severe depression in 1.3%. Depression occurs more commonly in adolescents than in prepubertal children and is more frequent in females than males after puberty.
Several risk factors contribute to the development of depressive disorders in adolescents (Box 66.1). Certain psychiatric conditions also are associated with depression, including generalized anxiety disorders, eating disorders, substance abuse, conduct disorders, and borderline personality disorders.
Suicide and Suicidal Behavior
Suicide is the second-leading cause of death in the United States in individuals 10 to 24 years of age; only motor vehicle crashes result in more deaths in young people. In 1960, the annual suicide rate in this age group was 5.2 per 100,000. The suicide rate has continued to rise over the past 50 years. According to the Centers for Disease Control and Prevention, the suicide rate in 2017 was 11.8 per 100,000, with 6,241 completed suicides in 15- to 24-year-olds. It has been stated that for every suicide that is completed successfully, 50 to 100 suicides are attempted. More than 75% of teenagers who committed suicide had not been on medication and were not under treatment for depression or suicidal concerns.
According to the 2017 Youth Risk Behavior Survey of the Centers for Disease Control and Prevention, 17.2% of all students in grades 9 to 12 nationwide had seriously considered attempting suicide during the previous 12 months. Approximately 14% of students nationwide had made specific suicide plans, more than 50% of students with suicide plans reported attempting suicide, and 2.4% of the individuals who attempted suicide required medical attention. The prevalence of developing a suicide plan was higher among gay, lesbian, and bisexual students (38.0%) and “not sure” youth (25.6%) than among heterosexual students (10.4%). Rates also differ by race and ethnicity, with black and Asian teenagers having lower suicide rates than white teenagers, and black females having the lowest suicide rate of all adolescents. American Indian/Alaska Native males have the highest suicide rate among this age group.
Box 66.1. Risk Factors Associated With Depressive Disorders in Adolescents
•Family history of psychiatric illness (eg, parent with an affective condition, another family member with a bipolar or recurrent unipolar disorder)
•Age at onset of depression in the affected parent; the earlier the age of onset, the greater the likelihood of depression in any children
•Exposure to an unexpected suicide attempt or completion in the school or community
•History of environmental trauma (eg, sexual or physical abuse, loss of a loved one)
•Certain medications (eg, propranolol, phenobarbital, prednisone)
In discussing adolescent depression and suicide, it is important to clarify the meaning of specific terms. Suicidal ideation is thoughts of engaging in suicide-related behavior. Suicidal intent is having the aim or resolve to follow through with a plan. Suicidal behaviors are behaviors related to suicide, including preparatory acts, suicide attempts, and death. Suicide attempt is a nonfatal, self-directed, potentially injurious behavior with any intent to die as the result of the behavior. A suicide attempt may or may not result in injury. Suicide is death caused by self-directed injurious behavior with any intent to die as the result of the behavior.
Several risk factors associated with adolescent suicide have been identified (Box 66.2). Suicide is rarely associated with depression but is most often associated with a recent, abrupt crisis (eg, breakup of a romantic relationship, accusation, failure). Although adolescent females are more likely to attempt suicide than males (22% and 12%, respectively), males are more likely to succeed (male-to-female ratio, 4:1). This fact may result from the lethality of the methods, such as firearms or hanging, that males usually choose. Although females are more likely to ingest pills, the role of firearms in suicide attempts or completion in females is increasing. The availability of firearms and alcohol, which varies from state to state, greatly contributes to the occurrence of suicide. Up to 45% of individuals who have committed suicide show some evidence of intoxication at the time of death. Although most suicide attempts are impulsive, studies have shown that adolescents often have communicated their suicidal intent or ideation to someone before the attempt. Approximately 50% of adolescents who attempt suicide have sought medical care within the preceding month and 25% within the preceding week. In contrast, only one-third have previously received mental health care.
Box 66.2. Risk Factors Associated With Suicide in Adolescents
•History of a previous suicide attempt (most important)
•History of adoption
•Lesbian, gay, bisexual, or questioning sexual orientation
•History of physical and/or sexual abuse or exposure to violence
•Family history of psychiatric disorders, especially depression, substance abuse, and suicidal behavior
•Personal mental health problems
— Sleep disturbances
— Psychological characteristics, such as aggression, impulsivity, and hopelessness or severe anger
— Preexisting psychiatric condition (eg, depressive/bipolar disorder, conduct disorder, posttraumatic stress disorder)
— Alcohol and illicit substance abuse or dependence
— Pathologic internet use
•Social and environmental issues
— Family disruption or stressful life event, including violence, divorce, or death of a loved one
— Impaired parent-child relationship
— Living outside the home (eg, homeless, corrections facility, group home)
— Exposure to an unexpected suicide attempt or completion in the school or community
— Availability of firearms in the home
The depressed or suicidal adolescent may visit a physician for a variety of clinical reasons, but rarely do they seek professional assistance for feeling “depressed.” Some adolescents have a difficult time accurately understanding and communicating their emotions. A depressed teenager often presents as irritable, argumentative, or angry rather than sad. Teenagers may exhibit diminished interest or pleasure in activities or relationships and changes in cognitive functioning (eg, concentration), sleep, appetite, or energy, which results in impairments in multiple activities of daily living. They also may present with seemingly nonemergent complaints and a flat affect or with multiple somatic concerns and an anxious appearance. Additionally, the teenager may have frequent visits to the primary care physician’s office for acute conditions that on first glance seem unrelated but later indicate possible substance abuse or a mood disorder. Some adolescents are accompanied by a family member or friend, which initially may make the teenager reticent to discuss psychosocial issues with the physician. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5), major depressive disorder (MDD) is diagnosed when at least 5 of 9 listed symptoms or signs occur for a duration of at least 2 weeks. At least 1 symptom must be sadness or loss of interest for most of every day, and a significant change in function must exist. Changes can manifest as poor academic performance; school attendance issues, including truancy and disruptive behaviors; and difficulties with peer and familial relationships (Box 66.1).
The exact neurobiologic etiology of depression remains elusive. It is believed to involve impaired serotonin and norepinephrine transmission in critical areas of the brain, most notably the frontal lobes. Like other complex psychiatric conditions, the etiology of depression seems to be multifactorial, with a strong genetic and psychosocial/ environmental basis. The genetic basis of depression is suggested by statistics that indicate, for instance, that 25% of children who commit suicide have a family member or close relative who has committed suicide. Similarly, a family history of major depression is a significant risk factor for depression in children and adolescents. Studies suggest the incomplete penetrance of a dominant gene as a possible etiology for this finding. Regardless of the exact mechanism, genetic influences can increase the adolescent’s vulnerability for depression. Specific environmental events can occur in an adolescent’s life that may precipitate a depressive episode, such as the loss of a loved one or parental divorce. Other events, such as physical or sexual abuse, also can trigger depression in a susceptible teenager.
The differential diagnosis of depression includes any condition that may alter an individual’s cognition or affect. For example, if a disease alters one’s nutritional status and leads to malnourishment, this may alter affect and energy, which may resemble depression (Box 66.3). Examples of such diseases include cancer, tuberculosis, and eating disorders (eg, anorexia nervosa). Endocrine disorders, such as hypothyroidism, hyperthyroidism, and Addison disease, can mimic depression. Central nervous system (CNS) pathology, although rare, includes tumors, infections, postconcussion syndromes, and cerebrovascular accidents. Concomitant systemic illnesses, such as systemic lupus erythematosus, diabetes mellitus, and AIDS, can have CNS manifestations that may be mistaken for an isolated episode of depression. Although these diseases can occur, their prevalence pales in comparison to the prevalence and significant contribution of substance and alcohol abuse. It is also important to recognize that many chronic conditions are stressful and can place patients at risk for comorbid depression. Other mental health conditions, such as early-onset bipolar disorder, can present initially with depressive symptoms. Approximately 20% to 40% of children with MDD eventually develop bipolar disorder. In contrast, longitudinal studies have found that very few individuals diagnosed with bipolar disorder as children meet criteria for the condition as adults. Another disorder to consider in children with depressive symptoms is disruptive mood dysregulation disorder, which was introduced in 2013 to identify those children with irritability and persistent, prolonged tantrums. Additionally, children with autism spectrum disorder often develop comorbid depression during adolescence as a manifestation of their isolation and poor coping skills. Other DSM-5 psychiatric diagnoses to consider include adjustment disorders, uncomplicated bereavement, separation anxiety, and dysthymia, which is more chronic and sometimes less severe than major depression. Finally, side effects of prescribed and over-the-counter medications may produce clinical symptoms consistent with depression and therefore should be considered in the differential diagnosis.
Box 66.3. Diagnosis of Depression in Adolescents
SIGE CAPS Mnemonic
S: Sleep changes
I: Interests—decreased interest in school or activities
G: Guilt, helpless, hopeless
E: Energy (decreased), fatigue
C: Concentration decreased
A: Appetite (increased or decreased)
P: Psychomotor agitation and retardation
S: Suicidal ideation
Criteria for Major Depressive Disorder
•Depressed or irritable mood most of the day, nearly every day
•Decreased interest in most daily activities, including school
•Significant weight changes
•Sleep problems (insomnia or hypersomnia)
•Psychomotor agitation or retardation
•Low energy or fatigue
•Feelings of worthlessness or guilt
•Diminished ability to concentrate or think
•Preoccupation with death or suicide