Karen Dineen Wagner, MD, PhD

The prevalence of depression has been increasing in youths. Depression in this age group is associated with impairments in peer relationships, family life, and academic performance. Of significant concern is the increased risk of 

 is essential to prevent the devastating sequelae of untreated depression in youth. Parents as well as teenagers should be educated about the symptoms of depression, its course, and treatments for this condition. Clinicians would benefit from educational materials to give to parents of depressed children, as well as updates about depression in youth.

American Academy of Child and Adolescent Psychiatry

 (AACAP), I focused on depression awareness and screening for my presidential initiative. Components of this initiative included education about depression in youths, expansion of the AACAP Depression Resource Center, and collaboration with professional organizations.

 With the participation of a stellar Task Force, the goals of the initiative have been achieved.

A number of resources have been produced as part of this initiative that are useful for clinicians who treat children and adolescents with depression, for parents, and for teenagers. The 

 contains up-to-date information about depression in children and adolescents. Importantly, there are resource sections specifically for clinicians, parents, and youth. The Depression Resource Center contains frequently asked questions about depression such as causes, signs and symptoms, course and treatments. Screening and rating scales for depression, books and Apps related to depression, and treatment resources and videos of clinician experts discussing depression as well as a video on depression for teenagers are included in the Resource Center.

Facts for Families on Depression in Children and Teens

 provides information for parents and youth about the symptoms of depression. It can be printed in a handout form for parents and teenagers.

The Parents’ Medication Guide on Depression

, a joint publication between AACAP and the 

, has been updated to provide information about medication treatment for depression in this age group. This medication guide is helpful for parents when clinicians plan to initiate medication treatment for depressed children.

Policy Statement on Depression Screening in Youth

. AACAP recommends routine screening for depression in children/adolescents ages 8 and older across health care settings, including primary care as well as mental health care settings.

 was published in Child and Adolescent Psychiatric Clinics of North America.

 The issue includes chapters on child and adolescent depression across settings (child welfare system, juvenile justice system, primary care setting, military setting, schools, colleges and home), comorbid clinical conditions (

, hearing impairment, medical conditions, HIV/AIDS, and substance use disorders), and ethnic and cultural identities (African American, Latino, American Indian, and 

). The aim of this edition is to assist clinicians who treat youths with depression to better understand unique aspects of assessment, course, and treatment of youths in these diverse populations.

 is an online CME course that was launched as part of the initiative. The course on depression uses video and lectures from past ACCAP activities on depression.

Journal of the American Academy of Child and Adolescent Psychiatry

 focused on depression and depression screening as part of this initiative. Some of the publications included a master clinician review on parental depression and family health and wellness

; a 13-year follow-up on psychotherapy effects on youth depression

; and mechanisms of change in a school-based depression prevention trial at the transition to high school.

Although the initiative is complete, the Depression Resource Center will continue to be updated to provide timely information for clinicians, parents, and youth.

 is Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX. She is Immediate Past President of the American Academy of Child and Adolescent Psychiatry, and she is on the Editorial Board of 

1. Wagner KD. Presidential address: Depression Awareness and Screening in Children and Adolescents. 

. 2018;57:6-7.
	2. Ng WY, Wagner KD. Depression in special populations. 

Child and Adolescent Psychiatric Clinics of North America. Clinics Reviews Articles.

 New York: Elsevier; 2019.
	3. Beardslee WR. Master clinician review: Parental depression and family health and wellness: what clinicians can do and reflections on opportunities for the future. 

. 2019;58:759-767.
	4. Eckshtain D, Kuppens S, Ugueto A, et al. Meta-analysis: 13-year follow-up of psychotherapy effects on youth depression. 

. 2020;59:45-63.
	5. Blossom JB, Adrian MC, Vander Stoep A, McCauley E. Mechanisms of change in the prevention of depression: an indicated school-based prevention trial at the transition to high school. 

Articles

Depression in children and adolescents is associated with several impairments but the most significant concern is the increased risk of suicide in youths with depression.

Depression Awareness and Screening in Children and Adolescents

Cannabis is a widely used drug of abuse in adolescents. With legalization of marijuana, adolescent cannabis use may increase substantially. Clinicians are often faced with a depressed, anxious, or suicidal adolescent who uses cannabis to self-medicate symptoms and is unwilling to stop using cannabis. Several recent studies provide further evidence of the adverse mental health consequences of cannabis use in adolescents.

A systematic review and meta-analysis examined the risk of adolescent cannabis use in the development of major depression, anxiety, and suicidal behavior.

 The analysis included longitudinal and prospective studies of cannabis use in adolescents aged younger than 18 years who were then assessed in young adulthood (aged 18-32 years). Eleven studies for a total sample of 23,317 adolescent cannabis users were included in the analysis.

The risk of depression (odds ratio [OR] = 1.4), suicidal ideation (OR = 1.5), and suicide attempt (OR = 3.5) in young adulthood was significantly higher in adolescent cannabis users than in nonusers; a significantly increased risk was not found for the development of anxiety disorders (odds ratio = 1.2). It is important to note that the increased risk of depression and suicidal behavior in young adulthood was present even in the absence of a premorbid psychiatric condition. Based on this study, the researchers concluded that the estimated population attributable risk of depression from cannabis use is 7.2% in adolescents; approximately 413,326 cases of adolescent depression are potentially attributable to cannabis use.

Age, cannabis use frequency, and mental health problems

The effects of age on cannabis use frequency and cannabis use disorder on psychotic, depression, and anxiety symptoms in adolescents and adults were evaluated by Leadbeater and colleagues.

 A randomly recruited sample of 662 adolescents aged 12 to 18 years was assessed over a 10-year period.

More frequent cannabis use was significantly associated with more depressive symptoms from ages 16 to 19 and after age 25. Furthermore, cannabis use was significantly associated with psychotic symptoms after age 22. There was no association between frequency of cannabis use and anxiety symptoms in the study sample. With regard to cannabis use disorder, there was an association with higher depressive symptoms at ages 19 to 20 and after age 25; psychotic symptoms after age 23 were associated with adolescent cannabis use disorder. Cannabis use disorder was also associated with higher anxiety symptoms at ages 26 to 27.

 examined the relationship between cannabis use and cognitive development in adolescents. The study sample included 3826 seventh graders (mean age, 12.7 years) from 31 schools in the Montreal area. These youth were assessed annually for 4 years (grades 7-10) on cannabis use, alcohol use, and cognitive functioning, including recall memory, perceptual reasoning, inhibition, and working memory. The assessments were completed via a confidential annual web-based survey during class time to assess cognition and substance use.

Adolescent cannabis and alcohol use were associated with lower working memory, perceptual reasoning, and inhibitory control. Of particular concern, cannabis use showed neuroplastic (concurrent effect) and neurotoxic (lasting effect) of cannabis, which was not found for alcohol use. For example, when adolescent cannabis use increased in frequency in a given year, there was a reduction in delayed recall memory and perceptual reasoning in that same year.

Cannabis use in a given year was also associated with impaired inhibitory control and working memory a year later. These findings are particularly worrisome given that cannabis use in this sample was low and infrequent, yet cognitive changes were detected with small increases in cannabis use.

Decreased threat responsiveness as a function of cannabis use disorder has been reported in adolescents.

 Eighty-seven adolescents with cannabis use disorder and/or alcohol use disorder were scanned with fMRI during a looming threat task. During this task, adolescents were shown images of threatening or neutral human faces or animals that appeared to be looming (increasing size over time) or receding (decreasing size over time).

Adolescents with higher severity of cannabis use disorder symptoms showed decreased response to looming stimuli within the rostral frontal and fusiform gyrus and amygdala. There were no associations with alcohol use disorder symptoms. The researchers speculate that decreased threat responsiveness may be a neurotoxic effect of cannabis abuse and related to conduct problems (less concern about negative consequences) associated with cannabis use disorder.

Mental health effects and increasing cannabis potency

The potency of cannabis with rising concentration of delta(9)tetrahydrocannabinol (THC) has been increasing over the past few decades. Wilson and colleagues

 reviewed the effects of increasing cannabis potency on adolescent health.

High-potency cannabis was associated with five times higher probability of having a diagnosis of a psychotic disorder compared with cannabis nonusers. Increased risk of relapse following first episode of psychosis was associated with frequent use of high-potency cannabis. In cross-sectional studies, high-potency cannabis use was associated with depression and anxiety in adolescent cannabis users. These findings are concerning because adolescents typically have little information about the potency of cannabis that they are using.

These recent studies add significantly to the evidence that cannabis use in adolescents has adverse effects on mental health with risk for depression, psychosis, and cognitive impairment, especially inhibitory control. Adolescents and their parents need to be informed about the adverse consequences of cannabis use, whether the adolescent is or isn’t currently using substances. Many psychiatric disorders increase the risk for cannabis use and conversely frequent cannabis use, especially higher potency cannabis, increases the likelihood of psychiatric disorders. With pending legalization of marijuana and increased access for adolescents, the public needs to be informed about the deleterious mental health effects of cannabis use in adolescents.

Dr Wagner is Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX. She is President of the American Academy of Child and Adolescent Psychiatry.

Gobbi G, Atkin T, Zytynski T, et al. Associations of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis. 

Leadbeater BJ, Ames ME, Linden-Carnichael AN. Age-varying effects of cannabis use frequency and disorder on symptoms of psychosis, depression and anxiety in adolescents and adults. 

Morin JG, Afzali MH, Bourque J, et al. A population-based analysis of the relationship between substance use and adolescent cognitive development. 

 Blair RJ, White SF, Tyler PM, et al. Threat responsiveness as a function of cannabis and alcohol use disorder severity. 

 Wilson J, Freeman TP, Mackie CJ. Effects of increasing cannabis potency on adolescent health. 

Cannabis is a widely used drug of abuse in adolescents. With legalization of marijuana, adolescent cannabis use may increase substantially.

More Reasons for Concern About Adolescent Cannabis Use

Anxiety disorders are the most common psychiatric condition in youth. Lifetime prevalence rates for any anxiety disorder in adolescents is 31.9%.

Anxiety disorders occur early in childhood with a median age of onset of 6 years. These disorders lead to significant impairment in academic, social, and family functioning. In clinical practice, it is common to see children who are homeschooled because of severe untreated anxiety disorders. Untreated anxiety disorders may also be a precursor for MDD. There have been some recent studies and meta-analyses that address mental health hospitalization, optimal treatment, and long-term outcome for children and adolescents with anxiety disorders.

 examined the incidence of mental health-related hospitalization, treatment for self-harm, and emergency room visits in children and adolescents who had a new diagnosis of an anxiety disorder. The sample included 198,450 youths aged 3 to 17 years who were included in the MarketScan claims database that contains health plan data for those covered by employer-sponsored private health insurance across the US. Youths were followed for up to 2 years after diagnosis of an anxiety disorder, and youths without anxiety diagnoses were included as comparators.

The median age of the youths with anxiety disorders was 12 years old and 55% were female. The incidence of new anxiety diagnoses were as follows: unspecified anxiety disorder (53%), generalized anxiety disorder (25%), obsessive-compulsive disorder (5%), and posttraumatic stress disorder (4%). Within a one-year period from diagnosis, 2% of these youths had a mental-health related hospitalization, 1% had a recorded suicidal ideation claim, and .08% had inpatient treated self-harm. Emergency room visits were high (20%), and 1.4% had an anxiety-related emergency room visit within one year of a new anxiety disorder diagnosis. The two-year incidence of these events was similar.

Rates of these events were highest in older children with baseline comorbid depression. Rates were lower in the comparator group (mental health-related hospitalization 0.5%, treated self-harm 0.01%, and emergency room visits 13%). Findings from this study further demonstrate the significant adverse effects of anxiety disorders in children and adolescents.

 examined the magnitude of antidepressant response and the effect of antidepressant class and dose on improvement in pediatric anxiety disorders. The anxiety disorders included generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. Data were obtained from 9 trials of antidepressant medications, which included 5 SSRIs and 4 SNRIs for 1673 youths with anxiety disorders who were randomly assigned to an antidepressant or placebo. The median duration of the treatment was 10 weeks. The SSRIs included fluoxetine, fluvoxamine, paroxetine, and sertraline. SNRIs included atomoxetine, venlafaxine, and duloxetine.

By week 2 there were statistically significant differences between medication and placebo, and by week 6 there were clinically significant treatment differences between antidepressant medication and placebo. There were also class differences in effectiveness between SSRIs and SNRIs. Compared with SNRIs, SSRIs showed significantly greater improvement by the second week of treatment, which was maintained through week 12.

There was no difference in response over time between high- and low-dose SSRI treatment; however high dose resulted in statistically significant improvement earlier (week 2) compared with low dose. The results of 

 demonstrate that response occurs early with antidepressant treatment of pediatric anxiety disorders and that SSRIs have earlier and greater efficacy than SNRIs for the treatment of children and adolescents with generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder.

 was undertaken to compare different types of psychotherapies for the treatment of children and adolescents with anxiety disorders.

 The study comprised 101 randomized clinical trials with a total of 6625 patients in the analyses. There were 11 different psychotherapies including:

• Individual BT with parental involvement

• Group cognitive behavioral therapy (CBT)

• Individual CBT with parental involvement

The 4 control conditions included wait list, psychological placebo, no treatment, and treatment as usual.

All of the psychotherapies were found to be more effective than the wait list control. Of all of the therapies, only group CBT was significantly more effective in treating anxiety symptoms than the other psychotherapies or the control conditions at both posttreatment and at short-term follow up (the median duration of acute treatment was 12 weeks and the longest follow up was 6 months). Based on these findings, the researchers suggest that group CBT may be the initial treatment for youth with anxiety disorders; however these findings require further research.

Child/Adolescent Anxiety Multimodal Extended Long-Term Study

 provides information about long-term outcome for youths who received acute (12 week) treatment for pediatric anxiety disorders.

 The study included 319 children and adolescents with separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder. Study participants were randomized to either 12 weeks of sertraline, CBT, sertraline plus CBT, or placebo. They were assessed annually over 4 years.

Across all 4 years, 21.7% of youth were in stable remission, 30% were chronically ill, and 48% relapsed. Those youths who responded to acute treatment were more likely to be in remission during the course of the follow-up. There was no association between the initial treatment group and remission status. These findings indicate that anxiety disorders in children and adolescents are often chronic and may require longer-term or intermittent treatment beyond acute treatment.

 Merikangas KR, He JP, Burstein M, et al. 

Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A)

 Bushnell GA, Gaynes BN, Compton, SN, et al. 

Incidence of mental health hospitalizations, treated self-harm, and emergency room visits following new anxiety disorder diagnoses in privately insured US children

. October 24, 2018; E-pub ahead of print.

The impact of antidepressant dose and class on treatment response in pediatric anxiety disorders: a meta-analysis

Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: a network meta-analysis

 Ginsburg GS, Becker-Haimes EM, Keeton C, et al. 

Results from the Child/Adolescent Anxiety Multimodal Extended Long-Term Study (CAMELS): primary anxiety outcomes

Recent studies and meta-analyses discussed here address mental health hospitalization, optimal treatment, and long-term outcome for children and adolescents with anxiety disorders.

Anxiety Disorders in Children and Adolescents: New Findings

Bipolar disorder in children and adolescents is a serious illness that adversely affects family, peers, and academic functioning. It increases risk for suicidality and is associated with high rates of occurrence. Bipolar depression presents a significant treatment challenge for clinicians. Although selective serotonin reuptake inhibitors are effective in the treatment of depression, they pose a risk of mania in children with bipolar disorder. There are now two FDA-approved medications: lurasidone and olanzapine/fluoxetine for the treatment of bipolar I depression in children and adolescents aged 10 to 17 years.

The efficacy and safety of lurasidone was investigated in a double-blind, placebo-controlled study of 347 youth aged 10 to 17 years with a diagnosis of bipolar I depression.

 Patients were randomized to lurasidone (n = 175) or placebo (n = 172) in this 6-week treatment study: 92% of the lurasidone group and 89.7% of the placebo group completed 6 weeks of treatment. The dose range of lurasidone was 20 to 80 mg daily, with a mean dose of 33.6 mg daily.

There was a statically significant difference from baseline to week 6 in the primary efficacy measure, Children’s Depression Rating Scale-Revised (CDRS-R) total score, between the lurasidone and placebo groups, favoring lurasidone. The effect size was medium, 0.45. Response rates (defined as ≥50% reduction from baseline to week 6 in CDRS-R total score) were significantly higher in the lurasidone group compared with the placebo group (59.5% vs 36.5%). The most frequent adverse events for the lurasidone were nausea and somnolence. There were no significant differences between the lurasidone and placebo groups on measures of suicidality, treatment-emergent mania, akathisia and extrapyramidal symptoms, cognitive function, weight and BMI, and lipid, glucose and prolactin levels.

The efficacy and safety of the olanzapine/fluoxetine combination (OFC) was evaluated in a double-blind placebo-controlled trial of 255 youths aged 10 to 17 years with bipolar I depression.

 Patients were randomized to OFC (n = 170) or placebo (n = 85) in this 8-week trial: 68.2% of the OFC group and 70.5% of the placebo group completed 8 weeks of treatment. The dose range of OFC was 6/25 to 12/50 mg daily with a mean dose of 7.7/37.6 mg daily.

There was a statically significant difference from baseline to week 8 in the primary efficacy measure, CDRS-R total score, between the OFC and placebo groups, favoring OFC. The effect size was medium, 0.46. Response rates (defined as ≥ 50% reduction from baseline to week 8 in CDRS-R total score and Young Mania Rating Scale item 1 score ≤2 at endpoint) were more significantly higher in the OFC group compared with the placebo group (78.2% vs 59.2%). Adverse events that were statistically significantly more in the OFC than the placebo-treated patients were weight gain, appetite increase, somnolence, sedation, and tremor. Mean weight gain for OFC-treated patients compared with placebo-treated patients was significantly greater (4.4 kg vs 0.5 kg). Patients in the OFC group had significantly greater increase in fasting total cholesterol, triglycerides, prolactin, and hepatic analytes. There were no significant differences in extrapyramidal symptoms and measures of suicidality between the patients receiving OFC and those patients receiving placebo.

Immediate release and extended release formulations of quetiapine have not demonstrated superiority to placebo in the treatment of adolescents with bipolar 1 depression. In a study of immediate release quetiapine, 32 adolescents were randomized to quetiapine 300 to 600 mg daily or placebo for an 8-week trial.

 There was no statically significant difference in CDRS-R scores from baseline to endpoint between the quetiapine and placebo groups.

In a study of extended release quetiapine, 193 patients were randomized to quetiapine extended release or placebo for an 8-week trial.

 There was no statistical significant difference in CDRS-R scores from baseline to endpoint between the quetiapine extended release and placebo groups. Potentially clinically significant elevations in triglycerides (9.3% quetiapine XR; 1.4% placebo) and thyroid stimulating hormone (4.7% quetiapine XR; 0% placebo) were reported.

The effectiveness of lithium for the treatment of 27 adolescents with bipolar depression was evaluated in an open-label 6-week study.5 Patients received lithium 30 mg/kg (twice daily dosing) to achieve a serum level of 1.0 to 1.2 mEq/L. There was a significant decrease in CDRS-R scores from baseline to endpoint. Response rate (defined as ≥ 50% reduction in CDRS-R scores from baseline to endpoint) was 48%. The most common adverse events were headache, nausea, vomiting, stomachache, and abdominal cramps.

Lithium is a potential agent in the treatment of bipolar depression in youth, however double-blind placebo-controlled studies of lithium are warranted to establish the efficacy of lithium in treating bipolar depression in youth.

Lamotrigine has been evaluated for the treatment of bipolar depression in adolescents as adjunct or monotherapy.

 Twenty adolescents with bipolar depression participated in a 8-week open-label trial of lamotrigine adjunct or monotherapy. The mean dose of lamotrigine was 131.6 mg daily. Response rate based on criterion of a ≥50% decrease in CDRS-R scores was 63%. The most common adverse effects were headache, fatigue, nausea, sweating, and difficulty sleeping. No rashes were attributed to lamotrigine.

Double-blind placebo-controlled trials of lamotrigine are needed to determine the efficacy of lamotrigine adjunct or monotherapy for adolescent bipolar depression.

In an open-label case series of 7 adolescents with bipolar depression treated with uridine 500 mg twice daily for 6 weeks, there was improvement in CDRS-R scores.

 Meanwhile, recruitment has been completed for a randomized, double-blind placebo-controlled 6-week trial of uridine as treatment for adolescents with bipolar depression.

Dr. Wagner is Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX. She is President of the American Academy of Child and Adolescent Psychiatry.

 DelBello MP, Goldman R, Phillips D, et al. Efficacy and safety of lurasidone in children and adolescents with bipolar I depression: a double-blind, placebo-controlled study. 

 Detke HC, DelBello MP, Landry J, Usher RW. Olanzapine/fluoxetine combination in children and adolescents with bipolar I depression: a randomized, double-blind, placebo-controlled trial. 

 DelBello MP, Chang K, Welge JA, et al. A double-blind, placebo-controlled pilot study of quetiapine for depressed adolescents with bipolar disorder. 

 Findling RL, Pathak S, Earley WR, et al. Efficacy and safety of extended-release quetiapine fumarate in youth with bipolar depression: an 8 week, double-blind, placebo-controlled trial. 

 Patel NC, DelBello MP, Bryan HS, et al. Open-label lithium for the treatment of adolescents with bipolar depression. 

 Chang K, Saxena K, Howe M. An open-label study of lamotrigine adjunct or monotherapy for the treatment of adolescents with bipolar depression. 

 Kondo DG, Sung YH, Hellem TL, et al. Open-label uridine for treatment of depressed adolescents with bipolar disorder. 

 University of Utah. Uridine Adolescent Bipolar Depression Randomized Controlled Trial. 

https//:clinicaltrials.gov/ct2/show/study/NCT01805440

Two FDA-approved medications are making a dent in treating bipolar disorder in youths, a serious illness that adversely affects young patients, as well as their family and peers.

Treatment of Bipolar Depression in Children and Adolescents

Dr. Wagner is Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX.

Recent studies have demonstrated the wide-reaching adverse effects of being bullied in childhood. These effects range from impaired academic performance to interest in cosmetic surgery.

 examined the relationship between bullying and academic performance. The study was made up of 965 third-grade children from public and private schools in Australia; 44.8% of the students were male. Bullying was assessed by child self-report on a bullying scale. The items on the scale included physical and verbal victimization. Reponses were yes or no; if yes, then information was obtained on the frequency of being bullied. Academic performance was assessed via a national achievement test that measured academic performance on 5 domains: reading, writing, numeracy, spelling, and grammar/punctuation.

Just over one-quarter (27%) of the girls and one-third (33%) of the boys reported being frequently bullied (defined as occurring once a week or on most days) during the past month. For boys, physical victimization was associated with lower numeracy scores compared with non-bullied peers. Boys who experienced both verbal and physical victimization had lower reading scores than boys who had not been victimized. For girls, verbal victimization was associated with lower writing and grammar/punctuation scores compared with those who were not bullied. Girls who experienced physical victimization had lower numeracy and writing scores. Girls who experienced both verbal and physical victimization had overall lower academic performance scores. In general, the academic delays were equivalent to approximately 6 to 9 months of learning for students who had experienced bullying compared with children who had not been bullied.

On the basis of these findings, the researchers recommend that prevention of bullying should be a major priority for primary schools. The findings suggest that teachers and parents should consider bullying as one possible explanation for their students performing below their academic expectation.

 examined the longitudinal association of bullying and substance abuse, as well as the role of depressive symptoms, in their study of 4297 5th-grade students. Students who completed baseline assessments and were evaluated in 7th and 10th grade were included in the study sample. Bullying (peer victimization) was assessed by use of a self-report questionnaire with items such as “How often do kids kick or push you in a mean way?” and “How often do kids tell nasty things about you to others?” in the past 12 months. Students were asked about their use of tobacco, alcohol, and marijuana in the past 30 days. Depressive symptom scores were obtained from items on a diagnostic interview depression subscale.

Students who reported being bullied frequently in 5th grade reported greater depressive symptoms in 7th grade. There was a positive correlation between 7th-grade depressive symptoms and 10th-grade alcohol use, marijuana use, and tobacco use. Overall, the experience of being bullied in 5th grade was associated with use of substances in 10th grade via the mediator of 7th-grade depressive symptoms. These findings were similar for girls and boys.

The results of this study demonstrate the lasting impact of bullying in elementary school into high school. Based on these findings, the researchers recommend that all youths be screened for bullying, depressive symptoms, and substance use.

 evaluated the association between bullying and access to a loaded gun without adult permission. Data were obtained from 10,704 students, aged 12 to 18 years, who completed the 2011 and 2013 School Crime Supplement (SCS) to the National Crime Victimization Survey. The SCS assessed school-based bullying during the current school year. Students reported whether they were bullied via traditional bullying (direct and indirect physical and verbal violence, social exclusion, and property damage) or cyberbullying (unsolicited sharing of private information online, social exclusion in electronic format, and threats or insults received via different cyber media). Access to a loaded gun without permission was obtained by self-report during the student’s current school year. Responses were yes, no, or don’t know to the following question: “Could you have gotten a loaded gun without adult permission either at or away from school?”

Access to a gun without adult permission was reported by 4.2% of the students. Students who experienced school-based bullying were 3 times more likely to report access to a loaded gun without adult permission than those students who are not bullied: 5.2% of those students who experienced traditional bullying; 9.2% of those who experienced cyberbullying; and 15.0% of those students who experienced both types of bullying reported access to a loaded gun without adult permission compared with 2.8% who experienced no bullying.

Given these findings, the researchers recommend that access to firearms be specifically addressed in evaluation of adolescents who report being bullied. This intervention may reduce the likelihood of self-inflicted injuries in adolescents who have been bullied.

 examined the association between bullying and interest in cosmetic surgery. Students from grades 7 through 11 were screened for bullying involvement (N = 2782). Bullying role (victim and/or perpetrator) was assessed by use of a self-report scale and peer nominations (adolescents identified other students who were perpetrators or victims of bullying). Psychological functioning was assessed using scales that measured self-esteem, body esteem, and emotional problems. Seven hundred fifty-two students (53.3% female) who screened positive for bullying involvement were assessed for their desire for cosmetic surgery. The evaluations were based on students’ responses to the following items:

1 “I would like to have cosmetic surgery so that others would find me more attractive.”

2 “I would consider having cosmetic surgery as a way to change my appearance so that I would feel better about myself.”

3 “If I was offered cosmetic surgery for free, I would consider changing a part of my appearance that I do not like.”

Responses to these items ranged from not at all to very much.

Bullying role and percentages were as follows: bully-victim (those who are bullied but also bully others; 39.1%); bully (19.5%); victim (18.2%; 67.6% of these were girls). Psychological functioning was significantly poorer for victims and bully-victims than for bullies and adolescents without a bullying role. Victims of bullying had the lowest self-esteem and lower body esteem than the other groups. Adolescents who had any role in bullying were significantly more interested in cosmetic surgery than adolescents uninvolved in bullying. The desire for cosmetic surgery was highest in victims and in girls compared with boys. Poor psychological functioning was associated with being bullied, which in turn led to increased desire for cosmetic surgery.

The researchers suggest that screening tools be used to assess bullying for individuals who seek cosmetic surgery. Treating the mental health impact of bullying may reduce the desire for cosmetic surgery and possibly unnecessary procedures.

 Mundy LK, Canterford L, Kosola S, et al. Peer victimization and academic performance in primary school children. 

 Earnshaw VA, Elliott MN, Reisner SL, et al. Peer victimization, depressive symptoms, and substance use: a longitudinal analysis. 

 Simckes M, Simonetti JA, Moreno MA, et al. Access to a loaded gun without adult permission and school-based bullying. 

 Lee K, Guy A, Dale J, Wolke D. Adolescent desire for cosmetic surgery: associations with bullying and psychological functioning. 

More Reasons to End Bullying

Following the holidays and the start of the New Year, adults often make renewed efforts to exercise. Physical and mental health can be affected positively by an increase in physical activity. Exercise has shown some benefits of improvement in depression for adults, but is there a relationship between exercise and depression in children and adolescents? Some recent studies shed light on this issue.

The relationship between physical activity and major depression in middle childhood was assessed in a prospective study.

 Six-year-old children (N = 795) in a community in Norway were followed up at age 8 and 10 years. Semistructured clinical interviews of parents and children were conducted to evaluate symptoms of major depression at each assessment. Physical activity was assessed using an accelerometer that was worn for 7 days during the assessment periods.

Higher levels of moderate to vigorous physical activity at age 6 predicted fewer major depressive symptoms 2 years later. Similarly, moderate to vigorous physical activity at age 8 predicted fewer major depressive symptoms 2 years later. There was no association between sedentary behavior and depression. On the basis of these findings, the investigators concluded that increasing moderate to vigorous physical activity in children may prevent future symptoms of depression.

The relationship between physical activity and depression was also recently studied in adolescents during the course of 11 years.

 Adolescents (N = 1160) with a mean age of 13 years completed questionnaires at 4 points, up to age 21. Depression was assessed by self-report using the Children’s Depression Inventory. Physical activity was assessed by self-report using the Leisure Time Exercise Questionnaire in which adolescents assessed their activity over the past 7 days and recorded the number of episodes of mild, moderate, and strenuous activity.

It was found that physical activity decreased over time and symptoms of depression increased over time. Higher initial symptoms of depression were associated with greater decreases in physical activity over time. The authors suggest that treatment strategies target symptoms of depression at about age 13 to prevent a decrease in physical activity and an increase in depressive symptoms.

Role of exercise in the treatment of depression

Given the association between physical activity and depression in youth, would exercise add benefit to the treatment of depression in youth? In the largest controlled trial to date, Carter and colleagues

 evaluated preferred intensity exercise for depressed adolescents. Adolescents (N = 87) who were in treatment for depression were randomized to either 12 sessions of aerobic exercise at preferred intensity along with treatment as usual or treatment as usual only.

The exercise consisted of circuit training with 8 exercise stations. The duration of each session was 1 hour. Exercise was defined as preferred intensity because the participants chose the order of the different exercises, chose the intensity at which they exercised, chose when to rest, and were not obligated to exercise at higher levels or attend the sessions.

The primary outcome measure to assess depression was the Children’s Depression Inventory. No significant difference was found between the preferred intensity exercise plus treatment as usual group and the treatment as usual only group at 6 weeks after the intervention. However, at the 6-month follow-up, the group that received the preferred intensity exercise had a significantly greater improvement in depressive symptoms than the group that received only treatment as usual. The investigators conclude that preferred intensity exercise in addition to treatment as usual may have benefit for adolescents receiving treatment for depression.

From an adolescent’s perspective, what aspects of exercise are beneficial to improve depressive symptoms? Carter and colleagues

 interviewed 26 adolescents with depression who had participated in the preferred intensity exercise program. The valued aspects of the intervention were as follows:

â¶ The importance of choice: being able to select exercise intensity and choice of whether to attend

â¶ Shared experience: being with other adolescents who were experiencing similar problems and concerns

â¶ A sense of achievement: doing something and feeling better about themselves

â¶ Routine: having a consistent routine in their lives

â¶ Being distracted: being able to focus attention on exercise and distract themselves from other problems and concerns

â¶ Feeling healthier: as a result of participating in exercise

The perceived changes reported by the adolescents were improved sleep; increase in energy; improved motivation to engage with peers, family, and school activities; improved mood; improvement in self-efficacy; better social interactions; and a more positive attitude toward exercise.

In light of these findings, clinicians may want to add exercise to the treatment armamentarium for depressed youth.

Dr. Wagner is Professor and Chair of the department of psychiatry and behavioral sciences at the University of Texas Medical Branch at Galveston. She is the Child and Adolescent Psychiatry columnist for Psychiatric Times.

Zahl T, Steinsbekk S, WichstrÃ¸m L. Physical activity, sedentary behavior, and symptoms of major depression in middle childhood. 

 Gunnell KE, Flament MF, Buchholz A, et al. Examining the bidirectional relationship between physical activity, screen time, and symptoms of anxiety and depression over time during adolescence. 

 Carter T, Morres I, Repper J, Callaghan P. Exercise for adolescents with depression: valued aspects and perceived change. 

 Carter T, Guo B, Turner D, et al. Preferred intensity exercise for adolescents receiving treatment for depression: a pragmatic randomised controlled trial. 

These studies shed light on the relationship between exercise and depression in children and adolescents. 

Exercise and Depression in Youth

[[{"type":"media","view_mode":"media_crop","fid":"54269","attributes":{"alt":"Â©AMBROZINIO /SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_2866485471573","media_crop_h":"243","media_crop_image_style":"-1","media_crop_instance":"6791","media_crop_rotate":"0","media_crop_scale_h":"250","media_crop_scale_w":"138","media_crop_w":"134","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© AMBROZINIO /SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]Immediate and short-term effects of childhood trauma have been a focus of clinical attention. However, recent studies demonstrate the far-reaching effects of childhood trauma related to depression and suicidality in adulthood. The evidence to support these associations is presented here.

 examined the relationship between adverse childhood experiences and suicidality in adulthood. Data were obtained from the 2012 Canadian Community Health Survey-Mental Health for men and women 18 years or older who completed information on adverse childhood experiences and suicide attempts. The adverse childhood experiences included sexual abuse, physical abuse, and parental domestic violence.

The survey comprised 22,559 persons. The mean age of the sample was 47 years; 51% were women. Of the total sample, 9.8% experienced physical abuse, 5.9% experienced sexual abuse, and 4.2% experienced parental domestic violence; 3% of the sample reported a history of having attempted suicide.

The prevalence of suicide attempts was significantly higher among those adults who had experienced trauma: physical abuse (12.4% vs 1.9% with no abuse) and sexual abuse (16.9% vs 2.1% with no abuse) as children; and among those who had witnessed parental domestic violence (7.3% vs 2.3% with no domestic violence). Gender did not moderate the relationship between childhood trauma and suicidality in adulthood. Depression, anxiety, substance abuse, and chronic pain accounted for some of the relationship between childhood trauma and adult suicidality. Of those factors, depression accounted for 25% of the association.

 studied the effects of childhood bullying in their review of prospective longitudinal studies of children who had been bullied. Children who were bullied had a high risk of depression and anxiety disorders in adulthood. They also frequently had higher rates of suicidal thoughts and plans than children who had not been bullied. The consequences of childhood bullying were worse for girls than for boys. Overall, the higher the frequency of childhood bullying, the worse the adult outcomes. These long-term effects of childhood bullying were found even after controlling for preexisting psychopathology.

Childhood trauma and antidepressant response

Not only does childhood trauma lead to increased risk of depression in adulthood, it can affect antidepressant treatment response in adults with major depression. Williams and colleagues

 assessed the role of early-life trauma in predicting acute response outcomes to antidepressants. The Early-Life Stress Questionnaire was used to gauge exposure to 18 types of traumatic events before the age of 18 years. The study enrolled 1008 adults with MDD and 336 healthy controls. The patients with depression were randomized to escitalopram, sertraline, or venlafaxine for 8 weeks.

Compared with healthy controls, patients with MDD had experienced significantly more childhood trauma: 62.5% of the participants with MDD reported more than 2 traumatic events compared with 28.4% of controls. Rates of sexual, physical, and emotional abuse; neglect; witnessing domestic violence; and bullying or rejection were significantly higher among patients with MDD compared with controls.

It is interesting to note that overall exposure to traumatic events did not predict a lower rate of antidepressant treatment response. It was abuse in particular that predicted this outcome. Childhood sexual, physical, and emotional abuse predicted poorer response and remission to antidepressant treatment, especially if the abuse occurred at age 7 years or younger. The researchers suggest that clinical management of depression include screening for childhood trauma to identify individuals who may not respond to initial antidepressant treatment and may need alternative therapy.

Maternal childhood abuse and offspring depression

 investigated the relationship between maternal childhood abuse and depressive symptoms in adolescent and adult offspring. Data were obtained from 2 large longitudinal cohorts of women (N = 8882) and their offspring (N = 11,402). Maternal history of abuse included physical, emotional, and sexual abuse. Depressive symptoms in offspring were assessed with depression scales. The investigators also obtained information about potential mediators of a relationship between maternal childhood abuse and offspring depression. Variables examined included maternal mental health, family characteristics (income, education, family structure), and offspring experience of abuse.

Close to three-quarters (73.9%) of the offspring had mothers who reported some exposure to childhood physical, emotional, or sexual abuse. Offspring of mothers who experienced childhood abuse had an elevated rate of high depressive symptoms from age 12 to 31 years. Compared with offspring of mothers who were not exposed to abuse, those of mothers exposed to childhood abuse were at greater risk for persistence of high depressive symptoms throughout adolescence and young adulthood. Offspring of mothers who had been severely abused were more than 1.5 times more likely to have high depressive symptoms and had approximately 2.5 times the risk of persistent depressive symptoms compared with offspring of mothers who had not been abused.

What accounts for the association between maternal childhood abuse and risk of high depressive symptoms in the offspring? Maternal mental health accounted for 20.9%; family characteristics, 0.3%; and offspring’s exposure to abuse, 30.3%. The researchers recommend screening for childhood abuse in pregnant women and mothers with young children so that interventions can be provided to decrease the likelihood of depression in their offspring.

Clinicians routinely inquire about exposure to abuse when they evaluate children and adolescents. These recent studies provide compelling data about the adverse effects of childhood trauma on adult outcomes-including higher rates of depression and suicidality, lower response rates to antidepressants, and higher risk of depressive symptoms in offspring compared with adults who had no childhood trauma. Adults, as well as children and adolescents, should be screened for a history of childhood abuse in order to provide appropriate interventions.

 Fuller-Thomson E, Baird SL, Dhrodia R, Brennenstuhl S. The association between adverse childhood experiences (ACEs) and suicide attempts in a population-based study. 

 Klomek AB, Sourander A, Elonheimo H. Bullying by peers in childhood and effects on psychopathology, suicidality, and criminality in adulthood. 

 Williams LM, Debattista C, Duchemin AM, et al. Childhood trauma predicts antidepressant response in adults with major depression: data from the randomized International Study to Predict Optimized Treatment for Depression. 

 Roberts AL, Chen Y, Slopen N, et al. Maternal experience of abuse in childhood and depressive symptoms in adolescent and adult offspring: a 21-year longitudinal study. 

Recent studies demonstrate the far-reaching effects of childhood trauma related to depression and suicidality in adulthood. The evidence to support these associations is presented here. 

Effects of Childhood Trauma on Depression and Suicidality in Adulthood

[[{"type":"media","view_mode":"media_crop","fid":"47881","attributes":{"alt":"Â© Jo millington/shutterstock.com","class":"media-image media-image-right","id":"media_crop_6131906001931","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5679","media_crop_rotate":"0","media_crop_scale_h":"145","media_crop_scale_w":"120","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Â© Jo millington/shutterstock.com","typeof":"foaf:Image"}}]]Four recent studies on medication for the treatment of pediatric bipolar disorder provide clinically relevant information. This article presents an update on the management of pediatric bipolar disorder based on these studies.

Although lithium has FDA approval for bipolar I disorder in youths aged 12 years and older, there have been no controlled trials of lithium for the treatment of youth with bipolar I disorder. Findling and colleagues

 investigated the efficacy of lithium for the treatment of youths aged 7 to 17 years with bipolar I disorder, mixed or manic episode in an 8-week double-blind, placebo-controlled trial. Fifty-three youths were randomized to treatment with lithium, and 28 youths were randomized to placebo. The mean lithium serum level at study endpoint was 0.98 mEq/L.

The lithium-treated youths had a significantly greater change in Young Mania Rating Scale (YMRS) scores than the placebo recipients. On the basis of Clinical Global Impression-Improvement scores, 47% of lithium-treated youth were very much/much improved compared with 21% of placebo-treated youth.

The most common adverse effects of lithium were vomiting (45%), nausea (43%), and headache (36%). The dose of lithium was reduced in half of the youths who experienced vomiting. For patients who received placebo, headache (32%), upper abdominal pain (32%), nausea (18%), and increased appetite (18%) were the most common adverse effects. There was no statistically significant difference in weight gain between those who received lithium (0.9 kg) and those who received placebo (1.2 kg). There was a statistically significant increase in thyrotropin concentration (3 mIU/L) with lithium compared with placebo (-0.1 mIU/L).

Here are four recent studies that provide clinically relevant information on medication management of bipolar disorder in youths.

Author | Karen Dineen Wagner, MD, PhD