Jeff Mitchell

Depression in Young People: Initial Presentation and Clinical Course

OBJECTIVEnThis project was designed to provide prospective data on the clinical presentation and longitudinal course of depression in children and adolescents.nnnMETHODnChildren and their parent(s) completed a structured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School Age Children) at intake, and then yearly for 3 years. Collateral data were collected on school, social, and family functioning.nnnRESULTSnMean length of initial depressive episode was 35.6 weeks, SD of 26 weeks. Of the 65 depressed youths who completed the 3-year follow-up, 35 (54%) disclosed another episode of depression. Demographic, family-environment, and diagnostic variables were explored as predictors of characteristics of initial episode, recurrence of depression, and psychosocial competence at follow-up. Female gender and presence of a coexisting anxiety disorder were significantly related to severity of initial depression. Family environment was the only predictor significantly related to overall psychosocial competence over 3 years.nnnCONCLUSIONSnThe findings confirm depression in youth as a valid clinical phenomenon, with substantial risk of recurrence. Increased levels of stress in the family environment were associated with poorer overall outcomes.

Parent and peer attachment in early adolescent depression

Insecure attachment relations have been theorized to play a significant role in the development of depressogenic modes of adaptation and to thus form a vulnerability factor for the emergence of depressive disorder in children. This study examined security of parent and peer attachment among four groups of early adolescents: clinically depressed, nondepressed psychiatric controls, nonpsychiatric controls, and adolescents with resolved depression. Depressed adolescents reported significantly less secure parent attachment than either of the control groups, and less secure peer attachment than the nonpsychiatric control group. Attachment security of adolescents with resolved depression was on a par with the nonpsychiatric control group. Among all psychiatric patients, security of attachment to parents was negatively correlated with severity of depression according to interview and selfreport ratings. Less secure attachment to parents, but generally not to peers, was also related to more maladaptive attributional styles, presence of separation anxiety disorder, and history of suicidal ideation.

Psychopathology in Parents of Depressed Children and Adolescents

One hundred and seventeen biological mothers and 63 biological fathers of depressed and nondepressed, psychiatrically disturbed children and adolescents were interviewed with the Schedule for Affective Disorders and Schizophrenia-Lifetime Version. Diagnostic information was also obtained on 54 biological fathers who were unavailable for interview. Histories of depressive disorders and other forms of psychopathology were reported at high rates in the parents. Major depression was the most commonly reported disorder in interviewed parents of both sexes, but it was reported more often in mothers. Substance abuse and antisocial pathology was more prevalent in fathers. Depression in parents did not distinguish depressed from nondepressed probands, but maternal history of anxiety disorders, alcoholism and/or drug abuse, and suicidality did. Depressed probands were more likely than their nondepressed peers to have two parents with histories of depression. Mothers of younger patients had more substance abuse and suicidality in their histories than mothers of adolescents. They also reported earlier age of onset of depression and earlier age of entry into treatment.

Risks for suicidality in major depressive disorder

This investigation developed a hierarchical multiple regression model to assess the potential risk factors for suicidality in youths 7 to 17 years old. Variables were assessed in three domains: self-perceptions, demography and diagnosis, and home/environment. The model controlled for major depressive disorder (MDD), which has confounded previous investigations, by evaluating potential risks in a diagnostically heterogenous sample, and then evaluating these risks in a subsample with MDD. Conduct problems and depressive thinking emerged as the most powerful predictors in both samples. Hopelessness, life stress, and maternal psychopathology predicted suicidality only in the total sample. Separation anxiety protected MDD youths. These results suggest that suicidal MDD youths may comprise a distinct subgroup of depressed youths.

Pediatric Cardiovascular Effects of Imipramine and Desipramine

Electrocardiograms were evaluated in 39 children and adolescents before and after the clinical use of imipramine and desipramine. The average increase in PR interval was 0.01 seconds. The PR interval increased by 0.02 seconds in 11 subjects, and a new first-degree atrioventricular block developed in two subjects. These changes were not related to the choice between imipramine and desipramine, the dose, or the method of administration. An increase in PR interval by 0.02 seconds or more did correlate with having an abnormality disclosed on a pretreatment electrocardiogram. The average increase in PR interval was 0.007 seconds for subjects with normal baseline electrocardiograms and 0.019 seconds for subjects with conduction and nonconduction abnormalities disclosed in baseline tracings. None of the electrocardiogram changes resulted in adverse clinical consequences.

Organic Diseases Mimicking Atypical Eating Disorders

The authors present three case studies of patients referred to Childrens Hospital and Medical Center, Seattle, Washington, for evaluation of possible eating disorders. The atypical manifestations of the cases warranted further investigation, which revealed an organic basis for their weight loss. The authors summarize the typical findings of bulimia and anorexia nervosa and discuss the clues from the case studies that mandated further evaluation.

Isolation and Restraint in Juvenile Correctional Facilities

Although mental health and correctional programs for juveniles house similar populations, their approaches to behavioral management can be quite different. This difference is evident in the use of isolation and restraint. Both of these interventions are effective behavioral management tools but are subject to abuse if not closely monitored. The authors, drawing from their experiences as mental health consultants to juvenile correctional programs and as expert witnesses in litigation, review the wide range of isolation and restraint practices in correctional programs and make recommendations for supervision and standardization.