PEDIATRIC DEPRESSION/ADOLESCENT SUBSTANCE ABUSE
From the 61st Annual Brennemann Memorial Lectures, presented September 30-October 3, 2004, by the Los Angeles
Pediatric Society
David Feinberg, MD, MBA, Associate Professor of Clinical Psychiatry, David Geffen School of Medicine at the
University of California, Los Angeles, and Medical Director, UCLA Neuropsychiatric and Behavioral Health
Services
General Background
| Major depressive disorder (MDD): extremely common; best described as combination of jet lag (tiredness and disoriented
biologic clock) and grief that lasts ≈2 wk; thoughts progress very slowly, as if “moving through chocolate pudding”;
associated with large decrease in productivity
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| Clinical presentation: often misdiagnosed and mistreated; 80% of patients with MDD present to primary care physician
with somatic symptoms (eg, headache, backache, tiredness); <20% accurately diagnosed; 20% present with psychologic
complaint (≈80% accurately diagnosed); 50% of high utilizers (patients who atttend primary care clinic ≥3 times in 12
mo) have MDD or anxiety disorder
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| Sex differences: before puberty, boys and girls affected equally; after puberty, MDD twice as prevalent in girls
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| Diagnosis: use jet lag and grief criteria, eg, difficulty sleeping, decreased appetite, disrupted thoughts, sadness, lachrymosity,
and acute sensitivity
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| Treatment deficits: only one third of patients treated appropriately; many receive suboptimal doses of antidepressants or
treatment of inadequate duration; treatment regimen should last ≥9 to 12 mo
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Issues in Pediatric Depression
| Prevalence of pediatric MDD: median onset of MDD 19 yr of age; half of all cases present in pediatric population
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| Diagnosing pediatric MDD: 1 wk of “jet lag and grief” sufficient for diagnosis; irritability often present in place of sad and
depressed mood; conduct disorder highly correlated
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| Treatment: maximum efficacy achieved with biopsychosocial approach
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 | Evidence for efficacy of antidepressants in children and adolescents: 1997—first study published demonstrating efficacy
of selective serotonin reuptake inhibitor (SSRI) for pediatric depression; study showed benefit of fluoxetine (Prozac) if
used over longer duration (12 wk) than previously studied; 13 previous studies showed no efficacy of SSRIs; 1998—
study of sertraline (Zoloft) for treatment of obsessive-compulsive disorder (OCD) showed doses of 50 to 200 mg appropriate
for children; 2001—speaker studied paroxetine (Paxil) for adolescent depression; no overall positive result
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| Prescribing: despite lack of data, SSRIs prescribed to many children and adolescents
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| Food and Drug Administration (FDA) investigation: in response to concerns over induced suicidal ideation, FDA conducted
meta-analysis of all trials of SSRIs for treatment of pediatric depression; accumulated data involved ≈4400 patients;
no suicides reported; 2.7% of patients (78) on active ingredient developed new-onset suicidal ideation,
compared to 1% for placebo; suicidal ideation appeared to develop at initiation of treatment and/or dose increase
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| Implications of FDA investigation: black-box warning now present on all SSRIs; over last 3 mo, 20% to 40% decrease in
antidepressant use in children and adolescents in United States; high rate of morbidity and mortality in untreated patients
with MDD (15%-25% completed suicide)
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| Recommendations for antidepressant use: only for moderate to severe depressive disorder; monitoring suitable for mild
cases; fluoxetine only drug with proven efficacy; if fluoxetine ineffective, inform parents of potential side effects of
other medications; discuss plans for taking child to emergency department and contacting physician
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| Treatment guidelines: wait 6 to 8 wk for medications to show efficacy; conduct weekly consultations for first 4 wk;
American Academy of Child and Adolescent Psychiatry states that telephone consultations acceptable; presence of
new agitation and/or akathisia indicates suicidal ideation; if treatment effective, continue for 6 to 9 mo; most medications
can be stopped “cold turkey”; taper paroxetine and venlafaxine (Effexor); treatment must begin in primary care
(scarcity of child and adolescent psychiatrists)
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| Recurrent depressive episodes: recommence treatment if depression returns within 2 yr (prevalence of relapse within 2 yr
≈50%); if pediatric patient suffers 3 full episodes, he or she should remain on medication for life
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| Cognitive-behavioral therapy (CBT): effective for treatment of major depression, OCD, panic disorder, tic disorder, social
phobias, and simple phobias
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| CBT for pediatric depression: children and adolescents (including those with low IQs) “good at” CBT; CBT addresses
negative triad, ie, negative view of self, negative view of world, negative view of future; therapist examines individual
cognitions and whether patient’s thinking distorts reality and causes overgeneralizations
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| Social elements: family functioning always affected by child with major depression; frequently, child is identified patient
for other family problems; important to educate family; identify and focus on child’s strengths
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| ADOLESCENT SUBSTANCE ABUSE
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Overview of Adolescent Mental Health
| Adolescent suicide: no higher than in other age groups; rate has increased from 5 per 100,000 in 1960s to 12 to 13 per
100,000 today (same rate as in all other age groups)
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| Mood fluctuations: beeper study analyzed differences in mood between teenagers and preteens; participants were randomly
beeped and asked to rate mood; results showed teenagers no more moody than preteens
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| Mental illness: prevalence in adolescents 20% (prevalence in adults 25%); decades-long questionnaire study shows 80% of
adolescents report no mental health problems, no conflict with parents, no conflict with cultural or societal norms, and no
negative feelings about themselves
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| Adolescent behavior: adolescents are healthy group; need to stop perpetuating myth of “normal teenage acting out”; don’t
minimize or overgeneralize teenage problems, “if teenager has a problem, it is a problem”
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Diagnosis and Treatment of Adolescent Substance Abuse
| Substance-use classification: drug use divided into 4 categories; no use—never had any drugs or alcohol; use—
experimentation with drugs and alcohol (majority of teenagers in this category); abuse—drug use that interferes with
normal daily living; dependence—drug use that is out of control (addiction); comment—abuse and dependence extremely
rare in adolescents; only 1% to 2% of adolescent mental illness results from substance abuse and dependence disorders
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| Diagnosis: 2 substance-use disorders in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-
IV), abuse and dependence
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| Abuse: defined by—degree of interference with daily living; social and interpersonal problems; response of parents and
social world; volume of consumption not part of diagnostic criteria
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| Case 1: parent discovers child using marijuana; child enrolled in drug treatment program; diagnosis of substance abuse
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| Case 2: parent discovers child using marijuana; parent discusses drug use with child and discourages use; child not entered
into drug treatment program; no diagnosis of substance abuse (disorder defined somewhat by parental reaction)
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| Dependence: inability to act on desire to quit; drug use despite physical problems; tolerance and withdrawal no longer
necessary for diagnosis; extremely uncommon in adolescents, probably because of school and family intervention;
also, adolescents have better livers, enabling more efficient drug metabolism
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| Drugs and psychologic well-being: adolescents who have never used drugs score lower on measures of psychologic health
than adolescents who have used drugs; drug experimentation almost normative phase for adolescents; United States, ≈5%
of world population, consumes ≈50% of illegal drugs
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| Obstacles to treatment: no data on treatment of adolescents for substance use or abuse (described as adult disorder); entire
literature on treatment of addiction based on dependence (disorder rarely seen in adolescents); existing treatments for
adults
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| Patterns of adolescent substance use: all data taken from Monitoring the Future study (www.monitoringthefuture.org);
data underestimate drug use; only monitors schools, so adolescents who have dropped out not included
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| Socioeconomic status: little difference in prevalence of drug use among adolescents in different regions of United States
and different socioeconomic strata
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| Ethnicity: American Indians and Latinos use more inhalants
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| Sex: girls now have same 1% rate of anabolic steroid misuse as boys
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| Prevalence: 47% of 10th graders have tried illicit substance (marijuana or something more significant); 8% of 12th graders
have experimented with cocaine; heroin use among 12th graders has tripled from 0.7% to 2.1% (national trend); 50% of
8th graders believe smoking cigarettes daily not dangerous to health
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| Universal primary prevention programs: evidence suggests that initiatives such as Drug Abuse Resistance Education (DARE)
program ineffective; “don’t do drugs” message being delivered to defined population (school) where half of individuals already
taking drugs (confusing message); adolescents introduced to DARE program have same degree of onset and severity
of drug problems as nonparticipants; program increases knowledge about drugs but not about drug abstinence
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| Targeted interventions: universal prevention programs need augmentation with specific, targeted programs for adolescents
at higher risk of developing drug problems
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| Indicators of high risk: untreated mental illness; family history of substance abuse; family-dynamic problems; poor
school performance
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| Effective treatment: teach high-risk adolescents problem-solving skills and networking skills (promote integration into
group); adolescents who already have drug problems should receive intense interventions
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| Clinical best practice: inform parents and children of reality of drug use in schools (parents underestimate, children overestimate);
difficult to attain ultimate goal of getting adolescent drug free; often have to start with harm reduction and decreased
use; speaker opposed to parents’ doing drug testing (often unhelpful in determining need for treatment); examine
history, perform physical examination, use laboratory tests as aid to diagnosis; important to develop close therapeutic relationship
with patients
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| Advice for parents: important to establish clear consequences of drug or alcohol use and to discuss these well in advance;
speaker emphasizes focus on school performance, friends, and engagement in family life; bad judgment, not drug use,
should be cause for concern
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| Advice for adolescents: speaker teaches adolescents to “put friendship on the line” and suggests socially acceptable diversionary
activity in response to pressure to do drugs; adolescents not willing to destroy friendships over drugs
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| Concluding remarks: drugs part of contemporary American teenage life; few positive role models; need improved dialogue
about psychiatric equivalent of bike helmets and car seats for prevention of adolescent substance use; drug use associated
with increased chances of physical problems, decreased school performance, and increased sexual promiscuity
and sexually transmitted diseases
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| How to identify adolescents at risk for substance abuse: identification difficult; lack of accurate indicators, eg, binge
drinking not diagnostic of future alcohol abuse; substance abuse not stable diagnosis, ie, disorder attenuates as part of
natural course; difficult to judge effectiveness of interventions
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| How to prevent adolescent who hasn’t used drugs from starting: big question for society; largely American problem;
need to tackle disastrous premise of adolescent drug use as matter of fact; drug-free college dorms example of place free
of pressure to do drugs
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| Effect of developmental issues and hormones on mental health: two thirds of parents say child has had difficulty with
puberty; when girls followed through development, none associate negative emotional states with puberty; boys associate
small amount of anxiety with spermarche; majority of teenagers go through changes with no sense of shame or anxiety
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| Rate of mental illness in childhood: lower than for adolescents; myth that adolescents disproportionately “crazy” group
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| Treatment of those who self-medicate for depression: need to address multiple problems; not treating psychiatric disorder
hinders treatment of substance-use disorder; individual with multiple diagnoses needs better psychiatric treatment;
historically, psychiatric treatment withheld until patient became sober; in adolescents, dual diagnosis of mental illness
with substance abuse is norm, not exception; adolescent with mental illness needs particular attention because likely to
experiment with drugs and exacerbate psychiatric disorder
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| What to say to parents who violate adolescent’s privacy: speaker tells all families and teenage groups that therapy is
“one-way street”; everything adolescent reveals remains private, except in cases of suicidal and homicidal ideation and
sexual abuse; adolescent informed of all communications with parents
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Educational Objectives
| The goal of this activity is to provide information on pediatric depression and adolescent substance abuse. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Diagnose depression in pediatric patients.
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| 2. Discuss the evidence for antidepressant use in children and adolescents.
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| 3. State the prevalence of adolescent mental illness and substance use.
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| 4. Recognize adolescents at risk for substance abuse.
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| 5. Employ a biopsychosocial approach to substance abuse treatment.
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Discussed on This Program
Fluoxetine HCl [Prozac, Sarafem]
Paroxetine HCl [Paxil]
Sertraline HCl [Zoloft]
Venlafaxine HCl [Effexor, Effexor XR]
Suggested Reading
Alderman J et al: Sertraline treatment of children and adolescents with obsessive-compulsive disorder or depression: pharmacokinetics,
tolerability, and efficacy. J Am Acad Child Adolesc Psychiatry 37:386, 1998; Battjes RJ et al: Evaluation
of a group-based substance abuse treatment program for adolescents. J Subst Abuse Treat 27:123, 2004; Brannigan R et
al: The quality of highly regarded adolescent substance abuse treatment programs: results of an in-depth national survey.
Arch Pediatr Adolesc Med 158:904, 2004; Brent DA: Antidepressants and pediatric depression—the risk of doing nothing.
N Engl J Med 351:1598, 2004; Courtney DB: Selective serotonin reuptake inhibitor and venlafaxine use in children
and adolescents with major depressive disorder: a systematic review of published randomized controlled trials. Can J Psychiatry
49:557, 2004; Curry JF et al: Cognitive-behavioral intervention for depressed, substance-abusing adolescents: development
and pilot testing. J Am Acad Child Adolesc Psychiatry. 42:656, 2003; Dasinger LK et al: Assessing the
effectiveness of community-based substance abuse treatment for adolescents. J Psychoactive Drugs 36:27, 2004; Deas D
et al: An overview of controlled studies of adolescent substance abuse treatment. Am J Addict 10:178, 2001; Emslie GJ et
al: A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch
Gen Psychiatry 54:1031, 1997; Emslie GJ et al: Fluoxetine treatment for prevention of relapse of depression in children
and adolescents: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry 43:1397, 2004; Findling
RL et al: Somatic treatment for depressive illnesses in children and adolescents. Child Adolesc Psychiatr Clin N Am
11:555, 2002; Jaffe SL: Treatment and relapse prevention for adolescent substance abuse. Pediatr Clin North Am 49:345,
2002; Kaminer Y et al: Cognitive-behavioral coping skills and psychoeducation therapies for adolescent substance abuse.
J Nerv Ment Dis 190:737, 2002; Keller MB et al: Efficacy of paroxetine in the treatment of adolescent major depression: a
randomized, controlled trial. J Am Acad Child Adolesc Psychiatry 40:762, 2001; Killen JD et al: Major depression
among adolescent smokers undergoing treatment for nicotine dependence. Addict Behav 29:1517, 2004; March JS et al:
Sertraline in children and adolescents with obsessive-compulsive disorder: a multicenter randomized controlled trial. JAMA
280:1752, 1998; Mohr WK: Updating what we know about depression in adolescents. J Psychosoc Nurs Ment Health
Serv 36:12, 1998; Newman TB: A black-box warning for antidepressants in children? N Engl J Med 351:1595, 2004; Nobile
M et al: A case-control and family-based association study of the 5-HTTLPR in pediatric-onset depressive disorders.
Biol Psychiatry 56:292, 2004; Rowan AB: Adolescent substance abuse and suicide. Depress Anxiety 14:186, 2001; Ryan
ND: Diagnosing pediatric depression. Biol Psychiatry 49:1050, 2001; Sen B: Adolescent propensity for depressed mood
and help seeking: race and gender differences. J Ment Health Policy Econ 7:133, 2004; Sitholey P: Pediatric depression
and psychopharmacology. Indian J Pediatr 66:613, 1999; Simkin DR: Adolescent substance use disorders and comorbidity.
Pediatr Clin North Am 49:463, 2002; Wagner KD et al: Efficacy of sertraline in the treatment of children and adolescents
with major depressive disorder: two randomized controlled trials. JAMA 290:1033, 2003; Waldron HB et al: On the
learning curve: the emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction
2:93, 2004; Weinberg NZ: Risk factors for adolescent substance abuse. J Learn Disabil 34:343, 2001; White AM et al:
Predictors of relapse during treatment and treatment completion among marijuana-dependent adolescents in an intensive
outpatient substance abuse program. Subst Abus 25:53, 2004; Wise BK et al: Dual diagnosis and successful participation
of adolescents in substance abuse treatment. J Subst Abuse Treat 21:161, 2001; Wong IC et al: Use of selective serotonin
reuptake inhibitors in children and adolescents. Drug Saf 27:991, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the speaker
reported no conflict.
Dr. Feinberg was recorded at the 61st Annual Brennemann Memorial Lectures, presented September 30 to October 3,
2004, by the Los Angeles Pediatric Society and held in San Diego. The Audio-Digest Foundation thanks Dr. Feinberg and
the Los Angeles Pediatric Society for their cooperation in the production of this program.
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