Peter Marton

Response to Desipramine Treatment in Adolescent Depression: A Fixed-Dose, Placebo-Controlled Trial

OBJECTIVE To determine the efficacy and tolerability of the tricyclic antidepressant desipramine (DMI) in the treatment of DSM-III-R-diagnosed major depressive disorder in adolescents. METHOD Sixty adolescents (42 female, 18 male; aged 15 to 19 years) diagnosed with major depressive disorder using clinical interview and Schedule for Affective Disorders and Schizophrenia for School-Age Children were randomized to receive either DMI (200 mg daily in divided doses) or placebo for six consecutive weeks following a 1-week placebo period. Treatment outcome was determined using the Hamilton Depression Rating Scale and the Beck Depression Inventory. Tolerability was determined using a symptom side effects scale. In addition, a variety of laboratory and cardiovascular monitoring was performed. RESULTS No significant differences in treatment outcome between DMI- and placebo-treated groups were determined. Neither DMI, nor its metabolite 2-hydroxy-DMI, nor their ratio, was positively correlated to treatment outcome. The DMI group endorsed more side effects but there were no significant between-group differences in any laboratory, electrocardiographic, or other cardiovascular parameters apart from heart rate, which was increased in the DMI-treated group (p = .03). CONCLUSIONS Given the findings of this study and our review of previously published reports of tricyclic antidepressant treatment in this population, the routine use of short-term (6 weeks) DMI in the treatment of adolescent depression is not supported by the data on hand. Further investigations into what constitutes optimal psychopharmacological treatment of adolescent depression are warranted.

Nocturnal Cortisol, Thyroid Stimulating Hormone, and Growth Hormone Secretory Profiles in Depressed Adolescents

Twelve depressed adolescents and 12 controls matched for age, sex, Tanner stage, time of menstrual cycle (females), weight, and time of year assessed were studied over 3 nights. Measurements for cortisol, thyroid stimulating hormone, and growth hormone were made on serum collected at 10 P.M., 12 midnight, 1 A.M., 2 A.M., 3 A.M., 4 A.M., and 6 A.M. in eight pairs and every 20 minutes from 8 P.M. to 7 A.M. in four pairs. Cortisol secretion did not significantly differentiate the groups. Thyroid stimulating hormone secretion was significantly elevated in the depressed group at one time point. Growth hormone secretion significantly differentiated the two groups at most time points, and the depressed adolescents significantly hypersecreted growth hormone (area under the curve). Implications for the diagnosis, etiology, and treatment of adolescent depression are discussed.

Relationship between psychiatric illness and conduct disorder in adolescents

Ninety-six psychiatrically ill adolescents admitted to an adolescent inpatient service were systematically assessed to determine the morbidity of conduct disorder (CD), with other Axis I psychiatric disorders. Twenty-six (27%) met DSM-111 criteria for CD in addition to other Axis I disorders. A CD diagnosis was significantly associated with substance abuse, and attention deficit disorder with hyperactivity. Although CD was found in 21 % of depressives it was more commonly found inpatients with psychotic disorders (25 %) and bipolar (42 %) disorders. These findings suggest that CD may be commonly found in a variety of adolescent psychiatric disorders. The implications of this finding for pharmacologic treatment of CD, the clinical assessment of the CD patient, and possible relationships between CD and adolescent psychiatric disorders are discussed.

Adolescent Bipolar Illness and Personality Disorder

The relationship between adolescent bipolar illness and personality disorder has not been explored. Studies of adult bipolars suggest a bipolar illness/borderline personality disorder (BPD) association. Twenty euthymic bipolar teens were assessed using the Personality Disorders Examination. Thirty-five percent met DSM-III-R criteria for at least one personality disorder. Three of the 20 (15%) had a borderline personality disorder diagnosis. The bipolar illness with personality disorder group differed significantly from the bipolar illness without personality disorder group in terms of increased lithium unresponsiveness (p less than 0.05) and neuroleptic treatment at time of personality assessment (p less than 0.01), but not in terms of age, sex, age of illness onset, serum lithium level, rapid cycling, substance abuse history, alcohol abuse history, or number of suicide attempts. Issues regarding the study of personality disorder in adolescent bipolars are discussed.

Epidemiology of firesetting in adolescents: mental health and substance use correlates

OBJECTIVE Despite high rates of firesetting among community adolescents, little is known about its correlates. This study identifies the mental health and substance use correlates of four firesetting levels in an epidemiological sample of adolescents. METHODS Three thousand, nine hundred and sixty-five (3,965) students in grades 7 to 12 were surveyed. Multinomial analyses were used to compare non-firesetters; desisters (lifetime, but no past-year firesetting); low frequency firesetters (once or twice in the past 12 months); and high frequency firesetters (3 + times) on measures of mental health and substance use. RESULTS Twenty-seven percent of youth reported firesetting during the past year. Of these, 13.7% reported one or two episodes, and 13.5% reported 3 or more episodes. Firesetting was more prevalent among males and among those in high school. Youth who began firesetting before age 10 were more likely to report frequent firesetting during the past year. Compared to non-firesetters, the firesetting groups had elevated risk profiles. Desisters and low frequency firesetters were more likely to report psychological distress, binge drinking, frequent cannabis use, and sensation seeking. Low frequency firesetters also reported higher rates of delinquent behavior, suicidal intent, and low parental monitoring than non-firesetters. High frequency firesetters reported elevated risk ratios for all of these risk indicators plus other illicit drug use. The cumulative number of risk indicators was positively associated with firesetting severity. CONCLUSIONS Firesetting is associated with psychopathology and substance use during adolescence. Findings highlight the need for programs to address the mental health and substance use problems that co-occur with firesetting.

Cognitive Social Skills and Social Self-Appraisal in Depressed Adolescents

OBJECTIVE This study was undertaken to determine whether the social cognitive skills and social self-appraisal of depressed adolescents differed from those of other adolescents with nonaffective psychiatric disorders or of adolescents free from disorder. METHOD Within the age range of 15 to 19, 38 depressed adolescent outpatients (14 boys, 24 girls); 31 nondepressed adolescent outpatients (17 boys, 14 girls); and 34 normal high-school students (18 boys, 16 girls) were assessed using the following dependent measures: Interpersonal Negotiation Interview, Adolescent Social Problem Solving Measure, Adolescent Self Perception Profile, and Interpersonal Dependency Inventory. RESULTS Depressed adolescents were found to have significantly more negative self-concepts and significantly less social self-confidence than either comparison group. They did not differ from the other adolescents in either social problem-solving ability or interpersonal understanding. CONCLUSIONS These results indicate that depressed adolescents have unique deficits in social self-evaluation which contribute to ineffective social behavior and the maintenance of dysphoric affect. Treatment of social skill deficits should be based on a careful assessment of the patients functioning in this area.

Personality dysfunction in depressed adolescents.

The personality characteristics of 35 consecutively assessed adolescents who met the DSM-III criteria for a current depressive disorder were assessed using independent structured interviews and paper and pencil measures. Sixty-five percent of the sample met the criteria for an Axis II personality disorder. The single most common diagnosis was borderline personality disorder (30%). Depressed adolescents with a concurrent personality disorder were less self-confident, displayed more neuroticism, and were emotionally reliant on others. They also demonstrated greater cognitive distortion. Teenagers who present with a depressive disorder warrant a comprehensive personality asessment. The combination of affective and personality disorder in such patients is associated with attitudes and interpersonal problems which should be therapeutically addressed in addition to symptomatic treatment of the depressed mood. Clinicians should be aware that depressed adolescents with personality disorder may be more likely to make a suicide attempt.

Successful clonazepam treatment of neuroleptic-induced akathisia in older adolescents and young adults: a double-blind, placebo-controlled study

In a double-blind, placebo-controlled trial of clonazepam in the treatment of neuroleptic-induced akathisia in older adolescents, clonazepam was significantly more effective at reducing akathisia scores at the end of the first treatment week than placebo (p < 0.0001). Clonazepam may be a safe and effective treatment for neuroleptic-induced akathisia in this age group.

Utility of the Beck Depression Inventory with Psychiatrically Disturbed Adolescent Outpatients

Thirty-seven consecutively assessed adolescents were evaluated at two intervals, one week apart, using the Beck Depression Inventory (BDI) and the Hamilton Depression Rating Scale (HLDRS). Scores on the two instruments were compared to each other and to the DSM-III clinical diagnosis. High scores on the BDI were not found to be specific to symptoms of patients with a diagnosis of depressive syndrome but rather measured the degree of subjective dysphoria. The severity of dysphoria was found to be greatest in the group with personality disorders and to vary most in this group from one week to the other. Suggestions for an appropriate use of the BDI in an adolescent population are made.

Familial Risk Factors Associated with Intrafamilial and Extrafamilial Sexual abuse of three to Five Year Old Girls

This study intended to identify familial risk factors which differentiate sexually abused young girls from nonabused girls and, further, young victims of intrafamilial from those of extrafamilial sexual abuse. The subjects were 112 girls aged three to five years and their families. Forty-two were the victims of intrafamilial sexual abuse and 28 were victims of extrafamilial sexual abuse while 42 girls were not the victims of abuse. The three groups of girls were matched for age. Comparisons indicated that the families of abused girls had less harmony and stability in the marital unit and were headed by less competent parents. Mothers in both abuse groups were significantly more likely to have experienced sexual abuse as children. For all comparisons, the intrafamilial group showed greater disadvantage and dysfunction than the extrafamilial group. The intrafamilial group was differentiated from the extrafamilial group by worse spousal relationships, inadequate boundaries in parent-child behaviour, fathers history of physical abuse as a child and violent behaviour as an adult and maternal disapproval of the child victim. These findings suggest that child sexual abuse is related to a longstanding collection of interconnected adult personal and relational deficiencies which result in inadequate parenting for the young victim.