Here Today, Here Tomorrow: Adult Outcomes of Adolescent Depression

Rachel G. Klein, PhD

Dr. Klein is Professor of Psychiatry, New York School of Medicine, Director, Institute for the Study of Anxiety and Mood Disorders, Child Study Center

Dr. Rachel Klein has been studying and treating psychiatric disorders in children and adolescents for over two decades. The recipient of multiple awards, Dr. Klein’s areas of expertise include conduct disorders, ADHD, anxiety, and affective disorders. An important issue in psychiatry is whether early psychopathology is linked to later dysfunction, and if so, what types of dysfunction. Studies of depression in the young (up to 18 years) have yielded divergent results, and while child depression appears to be linked to a variety of adult outcomes, there is no question that adolescent depression is correlated specifically with adult depression, though to what exact degree—and in what manner—is difficult to pinpoint.

Epidemiology

“We can’t say, for instance, that 50% of adolescents with depression will go on to have depression as adults. There’s just too much variability in the studies,” explains Dr. Klein. “What we can say is that adolescents with depressive symptoms are definitely more likely to present symptoms of depression as adults than are adolescents without depressive symptoms.” There is no hard, agreed upon number, but Dr. Klein estimates that adolescents with depression are at least twice as likely to have depression as adults than adolescents who do not experience a depressive disorder. Part of the difficulty in accurate prediction, she says, is the large variation in rates of adult depression in so-called “normals,” that is, adolescents with no history of depression. In some studies, as many as 40% of non-depressed controls we judged to have had a major depression during the follow-up period. “It is likely that numbers this high are reflective of some aspect of the proband population, though it’s anyone’s guess as to what that might be.”

Other studies have found much lower rates of adult depression at follow-up of both adolescents with depression and controls, but the general ratio of depressed adolescent outcomes to control outcomes stays roughly the same. Of particular importance is the finding that adolescent depression predicts subsequent suicide. A major study by Dr. Weissman put the prevalence of completed suicide at a whopping 8%.

“Evidence linking adolescent and adult depression is incontrovertible,” says Dr. Klein. “However, that is not the case with childhood depression.” Some studies have found no correlation between childhood and adult depression, but a study by Dr. Myrna Weissman found that childhood depression was correlated with later conduct disorders and substance abuse.

Atypical Depression

“In many cases,” Dr. Klein notes, “depressed adolescents’ symptom profiles are much closer to those of atypical depression than those of other depression.” She believes this has largely been overlooked, and might have significance for treatment. “Non-atypical depressives have pervasive lowering of hedonic level that does not respond meaningfully to external events, and present with early awakening and reduced appetite. Adolescents, however, are much more like atypical depressives; they sleep more, they often gain weight, and their depression doesn’t follow any particular diurnal rhythm.”

In Dr. Klein’s experience, adolescents with depression are subject to rapid reversals of mood in response to seemingly minor stimuli (for instance, being at a party where the adolescent receives positive attention could spur a return to normal mood, while a perceived slight from a friend could precipitate a powerful bout of depressive feelings). Atypical depression often has an early onset, so it’s possible that many cases of adolescent depression are just instances of particularly early onset atypical depression. There have been no clinical trials assessing MAOIs for adolescent depression, but if Dr. Klein’s hunch is correct, depressed adolescents might benefit from such treatments.

Childhood Depression

Childhood depression is even more poorly understood than adolescent depression. “People who study it say that it presents similarly to adolescent depression,” Dr. Klein says, “but that has not been my experience with childhood depression.” She has not seen the same symptom pattern in children as in adolescents. “Adolescents will be getting along well, and then during depression their grades go down, they stop caring about school, and they restrict their interests and social contacts. I have not seen that type of behavioral shift in a child. However, that’s just observation from one practice, and studies do document that children meet criteria for major depression. However, by all indications, childhood depression is rare, and any clinician might practice without having the opportunity to observe it in a range of patients.”

Conclusion

Adolescent depression and adult outcomes clearly are correlated. This knowledge is a valuable clinical tool. As Dr. Klein says, “Depression incurs a great deal of dysfunction, and the sooner you treat it, the better.” Clinicians should be alerted to the importance of the disorder in adolescents and its repercussions into adulthood.

Sources: http://jama.ama-assn.org/cgi/content/abstract/281/18/1707;
http://www.nami.org/Content/ContentGroups/Helpline1/Facts_About_Childhood_Depression.htm