From The Quarterly, Spring 2012

Adolescent depression is a worldwide mental health problem that often goes unrecognized, misdiagnosed and/or untreated. An in-depth review of the status of current scientific understanding of the disorder and of the available treatment approaches and resources appears in the Feb. 2, 2012 online edition of the journal The Lancet.

The mega-survey, a comprehensive search of the scientific and clinical literature going back five to 10 years, was conducted by a team of experts that included Brain & Behavior Research Foundation Scientific Council Member and NARSAD Independent Investigator Grantee Daniel S. Pine, M.D., Chief of the Section on Development and Affective Neuroscience at the National Institute of Mental Health (NIMH), and psychiatrists at the University of Cardiff, Wales, and in clinical practice. The good news the authors report is the emergence of promising prevention strategies for teens at highest risk.

The strongest risk factors for adolescent depression are family history, stress and sex hormones. Despite a three- to four-fold increased risk for children of depressed parents, genetic studies have yet to definitively identify specific inherited candidate risk genes. Many reports suggest one might be a variant of the serotonin transporter gene, but only when interacting with environmental stressors. The neurotransmitter serotonin is one of the chemicals of brain cell communication. The antidepressant drugs called selective serotonin reuptake inhibitors, or SSRIs, target the serotonin system. Both inherited factors and psycho-social stressors can affect neural circuits and endocrine systems. As with adult depression, females are at greater risk than males.

Adolescent depression differs from adult depression in treatment response. Tricyclic antidepressant medications, which can be effective for adults, are not effective for adolescents. Some SSRI antidepressants, like fluoxetine (Prozac) and escitalopram (Lexapro), can be moderately effective for adolescents, but there is controversy as to whether or not these drugs increase suicide risk. Depression in adolescents is a major risk factor for suicide, with more than half of adolescent suicide victims reported to have a depressive disorder at time of death.

Among psychosocial treatments, the best studied are cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). CBT has been shown to be moderately effective. One large study showed that the addition of CBT to antidepressant medication was beneficial against treatment-resistant depression. Studies also suggest that IPT can be useful, but there is not a large pool of therapists trained in the IPT technique.

In their conclusion, the authors of the survey note that in view of the complexities and costs associated with treatment of depression in adolescents, strategies to prevent, or at least delay, onset are important and show promise. They cite research indicating that combining education about depression with CBT can be effective when specifically targeted to children of parents who have had depression, to adolescents with subthreshold symptoms and to adolescents who have had a previous depressive episode. Preliminary evidence also suggests school-based CBT as promis-ing, as well as parenting programs. Finally, the authors’ state: “Quality of relationships seems key to enhance resilience in high-risk children.”