New Tool to Diagnose Adolescent Depression

The Centers for Disease Control and Prevention (CDC) estimates that between 1992 to 2004, the rate of hospitalization for depression has increased approximately 81% for females and 30% for males aged 5-19 years. In 2004, more than 5,000 US children and adolescents committed suicide and an additional 171,870 non-fatal self harm injury cases were reported. About 15-20% of American teens have experienced a serious episode of depression, which is similar to the proportion of depressed adults.

Eighty percent of the depression cases are readily treatable. But the numbers above state a different story. One possible reason could be improper diagnosis. Depression in adolescents can occur due stress associated with the normal maturation process. It can also occur as a result of a traumatic experience. It is however, difficult to diagnose depression in adolescents because it may manifest in several forms and can also be mistaken for normal teenage behavior.

Over the years, several different methods have been used to diagnose depression along with the physical examination. These include self-reports like the Center for Epidemiological Studies Depression Scale and Beck Depression Inventory and clinician reports like the Hamilton Depression Rating Scale and the Children’s Depression Rating Scale. These scales however, are not specific to adolescents and hence have been reported to have limited reliability in that age group. Also, these tests classify adolescents as either depressed or not depression and do not consider a substantial number of depressed teens with no apparent symptoms. Thus, some recently published studies have supported a dimensional model where depression is graded along a continuum from mild to severe.

In a study published recently in BMC Psychiatry, Dr. Revah-Levy et al. of the Université Paris Sud designed and tested a dimensional scale to diagnose adolescent depression called the Adolescent Depression Rating Scale (ADRS). Two initial versions of ADRS were constructed: one was a 11 item clinician-scale report and the other was a 44 item self-report scale. 402 adolescents were assessed and it was found that ADRS had acceptable psychometric properties.

This test has only been validated in French as of now but translations are being made into other languages. If successful, this can make a considerable difference in the way adolescent depression is diagnosed and that may in turn lead to better management of the disease and save so many young lives.

How Young is Too Young to Diagnose Depression?

Any parent can attest that the “Terrible 2’s” are a moody, temperamental time in the life of a toddler. Many kids are irritable and seem to throw temper tantrums for no reason, and some engage in more destructive behaviors like biting, hitting, and kicking themselves or others. Unfortunately, for some children, this phase lasts well beyond their third birthday. Are these kids just demonstrating the outward signs of emotional immaturity, or are they suffering from clinical depression? A new study funded by the National Institute of Mental Health and published in Archives of General Psychiatry suggests it may be the latter.

The provocative new research presents evidence that depression in preschool-aged children can be a chronic condition, not just a passing grumpy phase. The study evaluated more than 200 preschoolers, aged 3 to 6 years, for 2 years and included 4 mental health exams during the study period. At baseline, 75 children were diagnosed with major depression. This subset of children had the highest risk of subsequent depression at 12- and 24-month follow-up exams. Of the initially depressed children, 64% were either still depressed or experienced a recurrence of depression at the 6-month point, and 40% experienced continuing or recurring depression at 24 months. Nearly 20% of the children had symptoms of depression at all 4 exams.

Depression was most likely in children of mothers with depression or other mood disorders, as well as children who had experienced a traumatic event, such as the death of a parent or abuse. While most preschoolers are happy-go-lucky most of the time, depressed children are often sad and tend to play games with somber themes. A persistent lack of appetite, frequent temper tantrums, and sleep problems are also symptoms seen in depressed children. Further, excessive guilt and shame is an indicator of preschool-onset depression. Despite investigation, no evidence has shown that depressed preschoolers show developmental delays.

Treating depression in young children is controversial, though a growing number of young children are being prescribed powerful psychiatric medications. Many antidepressant medications contain warnings for adolescents, and most drugs have not been carefully examined in preschoolers. Most experts support psychotherapy as first-line treatment in children. The current study did not examine treatment in the study population.

Experts are wary of labeling preschool-aged children with depression, since the diagnostic tools for this age group are not well established. However, early identification of depression may save a child from a lifetime of social and emotional consequences. Many adolescents and adults present to health care providers for mental health treatment, indicating that their symptoms started at an early age, and most adults with depression did, in fact, meet diagnostic criteria for depression in childhood. However, if children are labeled as “depressed” so early in life, are they set up for a lifetime of medications and treatments and stigmatization?

Despite the controversy, and accuracy, of diagnosing depression in children as young as 3, new research highlights the need for communication among parents, teachers, and caregivers about a child’s emotional development. Early intervention may be the key to preventing depression later in life.

Problem Eating Behavior in Preschool Children

Greek physician Hippocrates once said, “If we could give every individual the right amount of nourishment and exercise, not too little not too much, we would have found the safest way to health.” According to the National Institutes of Health, at least one out of five kids in the U.S. is overweight. The number of overweight children continues to grow. Over the last two decades, this number has increased by more than 50% and the number of “extremely” overweight children has nearly doubled. The prevalence of underweight children has, however, decreased and only 1.6% children in the developed countries are underweight. Several factors can contribute to weight problems including improper caloric intake, genetics, and behavioral patterns.

In a study published in the International Journal of Behavioral Nutrition and Physical Activity, Lise Dubois and collegeues analyzed the social issues that cause problem eating behavior and in turn, the effects of this behavior on the weight of preschoolers. They analyzed 1,498 children from the Longitudinal Study of Child Development in Canada and observed that eating behaviors in children range from picky eating, irregular eating, overeating and binge eating. Factors like low birth weight and insufficient income contributed to picky eating. Single-parent family status, obese or overweight parents and gender played a role in overeating. Interestingly, low family income was a factor in overeating as well. A greater proportion of picky eaters were underweight at 4.5 years while overeating contributed to being overweight at that age. This study establishes a strong connection between family environment and weight problems.

Research in the past has shown that childhood weight issues could continue into adolescence and adulthood. Thus, a comprehensive program involving parents, teachers and children should be implemented all over the country. “Prevention is a marathon, not a sprint,” says Linda Johnson, Director of School Health Programs for the North Dakota Department of Public Instruction. The Departments of Health and the Surgeon General’s Office have issued several guidelines like Physical Activity Guidelines for Children, Youth and Adults; Bright Futures in Practice: Nutrition; and Guidelines for childhood obesity prevention programs to name a few. But, it is important to spread awareness about these resources to teachers, children and parents. This is important to help children who are suffering unnecessarily from long-term health and emotional impacts of adult-like medical problems at younger ages.

How Do We Feed Our Children?

Tonight my son ate a sweet potato. And a few pieces of pasta. And a sauteed mushroom. And some watermelon. And a few kidney and Garbanzo beans. Oh and a few bites of chocolate and vanilla ice cream.

It was a good eating day. Some (read between the lines: most) days sitting down to eat looks more like a game of throw your food on the floor than it does anything else. And then there are the days that he doesn’t throw his food but he only wants to eat one certain thing… a whole lot of cantaloupe or crackers or, my attempt at a somewhat healthy snack, an organic, no-sugar added fruit roll-up thing. Usually those are the days that I don’t have a lot of that one certain food he wants. Of course.

But my frustration with food does not stop there. Just deciding what food to even try to get him to eat is a source of endless frustration. My criteria list is so long and exhaustive that sometimes I just want to ignore the whole food issue altogether. I mean by the time I’ve found food that is:

• Fresh – more nutrients
• Fairly produced — want others to make a living
• Local – better for the environment and supposedly keeps more nutrients
• Cruelty free — don’t want antibiotic-filled milk or caged chicken eggs
• Affordable – $8.00 for a pound of strawberries is a bit much
• Accessible – going to 7 different stores each week isn’t possible
• Somewhat kid-friendly – turnips aren’t going to be an easy sale

I’m tired. And since I’m not quite sure Baby is even going to eat the food and since there is a good chance that a bit of it will end up on my mop… well, you the issue is clear.

Probably the most frustrating thing to me is all the contrary advice and information I hear. I know that many people feel this same way; it’s the whole eggs are good for you one day, bad for you the next, and then good for you again.

Along with the changing information are the reports about how a good food may be bad depending on the pesticides used (Do the nutrients in grapes cancel out the chemical traces we’re eating?) or the container it is stored and shipped in (So is bottled water bad?). And then Wendy Moore’s article, Food, injurious food, dropped in my lap. The article is mainly about all the fillers and gross “ingredients” a 19th century London doctor discovered when he started studying food under his microscope.

Ahhhh; what a breath of fresh air!

I know; that sounds odd. But for some reason it felt good knowing that there have always been issues surrounding the safety and quality of food. It makes me feel the same way I do about war or violence… it has always been around. So, although I’m still not sure how to best feed my babe, I can at least rest in the knowledge that few others do either.

Food Additives, Hyperactivity, and Common Sense

A BMJ editorial, Food additives and hyperactivity, discusses the recent attention that the European Food Safety Authority (EFSA) has been giving to the possible link between food additives and childhood hyperactivity. Apparently the EFSA had to re-evaluate studies regarding this possible connection after publishing an opinion that suggested that there wasn’t enough evidence to suggest a correlation between additives and hyperactivity.

The editorial mentions various treatment options for hyperactivity. Apparently there is substantial evidence backing up two common therapies for this problem: drugs and dietary modification. But there is little evidence to justify treating this problem with behavioral therapy, even though this is a common procedure.

It is interesting to note that there is quite a bit of focus on both drug and behavioral therapies. But Andrew Kemp, the author, notes that it would be wise to eliminate various additives that have been shown to affect the behavior of children. After all, even though the evidence may not be staggering, there is still indeed evidence that shows this.

It is ironic to me that Kemp even needs to suggest this; it sounds like this “advice” is common sense. I know that many people treat various aliments with more natural approaches such as dietary changes, as we’ve discussed here, or with other changes such as exercise, meditation, light-therapy, etc. The list is endless. And honestly I’m quite envious of people who have successfully been able to do this well.

I believe that a good number of people (myself included) have strayed from the common sense approach to treating physical and emotional ailments. We’ve relied on drugs and other “easy” methods to the point that it seems extreme to try other, gentler methods.

Now be clear. I am not saying that people shouldn’t take drugs or are lazy if they do. That’s not my point and certainly not even my implication. Therapeutic drugs have a place in our treatment of illnesses just as yoga and sugar-free diets do. And taking drugs, while not void of all complications or issues, is usually more straight-forward than other therapies. (Our society and western viewpoint of illness is partially responsible for this but that’s another topic.) And I know that I too, look to those educated in these matters, to help me choose the best treatment option. And natural solutions, while agreed that they may be viable, are not usually the course of action relied upon.

While I hope that our health care system eventually becomes more well-rounded, I understand that doctors will continue to rely on the regulated, scientific-based methods for years to come. And that’s fine. In fact, I understand why they would be hesitant to suggest something that isn’t based on scientific evidence or that isn’t governed by a regulatory system. That’s why I think it’s up to us as patients to take a second to consider common sense solutions to our everyday health problems. Maybe they will help, maybe not. But at least we’ll be adding balance to our somewhat narrow-minded western viewpoint of medicine.

How Strong is Your Evidence?

If you’ve had heart problems, chances are you’ve received some advice from your doctor on how best to care for your condition. Maybe you were advised to take an aspirin daily, exercise regularly, or cut down on the salt in your diet. Maybe you were handed a sheaf of prescriptions bearing foreign-sounding medication names with the assurances that they would help stave off future problems. And if you’re like many patients, you took the doctor at his or her word, assuming he or she was acting based on sound medical evidence. Unfortunately, that assumption may have been false.

The push in medical education for several years has been towards more evidence-based medicine; that is, we should teach our young doctors to recommend to their patients what has been scientifically proven to be beneficial. However, a recent study published in the Journal of the American Medical Association (JAMA) found that, at least with regards to cardiovascular problems, the vast majority of the medical evidence supporting current recommendations is weak. Researchers examined the current recommendations of the American Heart Association and the American College of Cardiology on 22 different cardiovascular topics. They graded the strength of the evidence supporting these recommendations from A to C, with A being the best evidence, and C being very little or weak evidence. Only 12% of the recommendations were in the A category. A staggering 45% earned a C.

There are many potential reasons for this, not the least of which is simply the lack of powerful data. The ideal medical study is a large, multicenter, randomized, double-blind, controlled trial funded by an organization with no vested interest in the outcome. The closer a study comes to this ideal, the stronger the evidence is to support its findings. However, many studies fall short of this ideal on numerous fronts. They involve a small or restricted subgroup of patients. They’re performed at only one medical center. They’re funded by the company that makes the medication or device being studied. Any of these shortcomings call the results of the study into question and weakens the strength of the evidence. Can these findings be applied to a larger or less restricted population? Can the results be reproduced at a different hospital? Are the researchers biased towards finding a positive outcome for the company that funds their research?

So should you ignore the majority of what your doctor says for lack of strong evidence? Not necessarily. Most doctors are simply working with the best information they have, even if the data supporting it is weak. What studies like this highlight is the need for better research to ensure that our recommendations are based on sound scientific evidence.

Healthy habits reduce heart failure risk

Heart failure is increasingly common and is associated with a death rate of between 20 and 50% after onset. Repeated hospitalization and impaired quality of life, because of symptoms, are linked to heart failure, making it an urgent public health issue.

Yet we know little of the lifestyle factors that may impact heart failure risk. A new report from the long-running Physicians’ Health Study now shows how adopting healthy habits could really reduce your chances of developing heart failure.

Researchers at Brigham and Women’s Hospital, and Harvard Medical School, studied nearly 21,000 men of average age around 54 years who were healthy at the start of the study. Six modifiable lifestyle factors were assessed: body weight, smoking, exercise, alcohol intake, consumption of breakfast cereal and consumption of fruits and vegetables. There were 1,200 new cases of heart failure and 4,999 confirmed deaths in the follow up time of 22 years. Overall, the lifetime risk of heart failure was 13.8% at age 40 and remained constant to age 70.

Having a normal body weight, never smoking, regular exercise, moderate alcohol intake and consumption of breakfast cereal, fruit and vegetables were linked to lower lifetime risk of heart failure compared to corresponding unhealthy behaviors. Men adhering to none of the six desirable lifestyle factors had a one in five lifetime risk of heart failure, while those adhering to four or more of the factors had a one in ten lifetime risk of heart failure. In other words, healthy living could reduce your risk of heart failure from 20% to 10% - a worthwhile goal.

Respiratory Disease

New data from a four-year study of 11.5 million Medicare enrollees show that short-term exposure to fine particle air pollution from such sources as motor vehicle exhaust and power plant emissions significantly increases the risk for cardiovascular and respiratory disease among people over 65 years of age. The study, funded by the National Institute of Environmental Health Sciences, a component of the National Institutes of Health, is the largest ever conducted on the link between fine particle air pollution and hospital admissions for heart- and lung-related illnesses.

The study results show that small increases in fine particle air pollution resulted in increased hospital admissions for heart and vascular disease, heart failure, chronic obstructive pulmonary disease, and respiratory infection. "The data show that study participants over 75 years of age experienced even greater increases in admissions for heart problems and chronic obstructive pulmonary disease than those between 65 and 74 years of age," said National Institutes of Health Director Elias A. Zerhouni, M.D.

The National Institute of Environmental Health Sciences and the U.S. Environmental Protection Agency provided funding to researchers at the Johns Hopkins Bloomberg School of Public Health for the study. The study results are published in the March 8, 2006 issue of the Journal of the American Medical Association.

According to the study, these findings document an ongoing threat from airborne particles to the health of the elderly, and provide a strong rationale for setting a national air quality standard that is as protective of their health as possible.

"These findings provide compelling evidence that fine particle concentrations well below the national standard are harmful to the cardiovascular and respiratory health of our elderly citizens," said NIEHS Director David A. Schwartz, M.D. "Now that the link between inhaled particles and adverse health effects has been established, we must focus our efforts on understanding why these particles are harmful, and how these effects can be prevented."

Fine particle air pollution consists of microscopic particles of dust and soot less than 2.5 microns in diameter ? about thirty times smaller than the width of a human hair. These tiny particles primarily come from motor vehicle exhaust, power plant emissions, and other operations that involve the burning of fossil fuels. Fine particles can travel deep into the respiratory tract, reducing lung function and worsening conditions such as asthma and bronchitis.