American Journal of Men's Health

http://jmh.sagepub.com Depression: Focus on the Adolescent Male

David J. Breland and M. Jane Park Am J Mens Health 2008; 2; 87 DOI: 10.1177/1557988307310958 The online version of this article can be found at: http://jmh.sagepub.com

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Adolescent Male Health

Depression: Focus on the Adolescent Male

David J. Breland, MD, MPH, FAAP, and M. Jane Park, MPH

American Journal of Mens Health Volume 2 Number 1 March 2008 87-93 2008 Sage Publications 10.1177/1557988307310958 http://ajmh.sagepub.com hosted at http://online.sagepub.com

Scope of the Problem

Adolescent depression is a significant public health problem with substantial consequences for health and well-being. Depression among adolescents was thought to be nonexistent for many years and considered a disorder of the middle aged and elderly (Evans et al., 2005). Research has documented that the first onset of major depression commonly occurs in adolescence and young adulthood (Evans et al., 2005). Depression is the most widely studied mental health problem because of its impact on individuals, families, and society and its link to suicide. Adolescent depression can be a chronic, recurrent, and serious illness (Evans et al., 2005). The lifetime prevalence of depression among adolescents is currently estimated to be 14.0% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005). In 2004, an estimated 2.2 million adolescents aged 12 to 17 had at least one major depressive episode (MDE) (SAMHSA, 2005).1 Among those in this age group who reported having experienced an MDE in the past year, less than half (40.3%) received treatment for depression during that time (SAMHSA, 2005). At any given point in time, about 3% to 8% of adolescents are facing a major depressive disorder, making it more common than asthma and any other chronic medical condition for this age group (Jackson & Lurie, 2006). Depression is more common among males before puberty. This shifts in adolescence, when the prevalence becomes more common among females (Evans et al., 2005; Jackson & Lurie, 2006). Although more prevalent in adolescent females, depressive symptoms and the diagnosis
From the Division of Adolescent Medicine, Department of Pediatrics, School of Medicine, University of California, San Francisco (DJB, MJP) . Address correspondence to: David J. Breland, 3333 California Street, Suite 245, Box 0503, San Francisco, CA 94143-0503; e-mail: brelandd@peds.ucsf.edu.

of depression have a significant impact on male morbidity and mortality. Depressive symptoms and suicidal thoughts or attempts in adolescent males are present and impact daily functioning. The Centers for Disease Control and Preventions Youth Risk Behavior Surveillance System (YRBSS) administers a national survey that includes a broad measure of depressive symptomatology in adolescents. The 2005 YRBSS assessed the following to gauge depressive symptoms: During the past 12 months, did you feel so sad or hopeless almost every day for 2 weeks in a row that you stopped doing some usual activities? One in five males (20.4%) reported this level of sadness. The 2005 YRBSS reports on suicidal thoughts and behavior. Among high school males within the past 12 months, 12% had seriously considered attempting suicide, 9.9% had made a plan about how they would attempt suicide, 6% had attempted suicide one or more times, and 1.8% had a suicide attempt that resulted in injury, poisoning, or overdose that was treated by a doctor or nurse (Youth Risk Behavior Surveillance System, 2005). Using the Center for Epidemiological StudiesDepression Scale to examine degrees of depressive symptomatology, Rushton et al. reported that 5.9% of males met criteria for moderate or severe depression within the past week (Rushton, Forcier, & Schectman, 2002).

Depressive Symptoms in the Male

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic crite1. Major depressive episode (MDE) is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had symptoms that met the criteria for major depressive disorder as described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). It should be noted that no exclusions were made for MDE caused by medical illness, bereavement, or substance use disorders.

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Table 1.

Criteria for Major Depressive Episode

A/PI-NH Hispanic Black-NH White-NH AI/AN-NH 0 15 30 Rates per 100,000 10.2 8.5 13.5 9.9 16.3 7.5 19.0 14.2 46.8 41.4 45 60

1. Depressed mood most of the day (for children and adolescents, it also can be an irritable mood) 2. Markedly diminished interest or pleasure in all or almost all activities 3. Clinically significant weight loss in the absence of dieting or weight gain or a decrease in appetite 4. Insomnia or hypersomnia 5. Observable psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feeling of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Source: Criteria adapted from the American Psychiatric Association (DSM-IV), 1994.

ria for depressive disorders are the same for adolescents as adults (see Table 1) (American Psychiatric Association, 1994). However, there are gender differences in symptom presentation. Boys seem to develop more overt aggressive behavior throughout the elementary and latency years (Jackson & Lurie, 2006). Although there are a few exceptions (Grant et al., 2002), most studies have identified that male adolescents react to a depressed mood in a more hostile, angry, and behavioral manner, whereas girls react in a ruminative (i.e., negative cyclic thinking) manner (Jackson & Lurie, 2006). Evidence from qualitative research on adults suggests that men demonstrate high-risk maladaptive behaviors as a means of ameliorating depressive symptoms and are more likely to decrease reporting of these symptoms to avoid signaling distress and showing signs of weakness and vulnerability (Brownhill, Wilhelm, Barclay, & Schmied, 2005). More research is needed in the area of gender differences among adolescents in the presentation of depressive symptoms in order to help facilitate identifying teen males at risk for depression and suicide.

Suicidality
Suicide is the third leading cause of death for adolescents, and depressive disorders increase the risk of suicide (Jackson & Lurie, 2006). Among 15- to 19year-olds, boys had a higher suicide rate than girls

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Race/Ethnicity

A major depressive episode is indicated by the presence of five or more of the following symptoms nearly every day during the same 2-week period, representing a change from the previous level of functioning:

1994 2004

Figure 1: Suicide rates per 100,000 Males Ages 15-19 1994 & 2004 A/PI = Asian Pacific Islander; NH = non-Hispanic; AI/AN = American Indian/Alaskan Native

(12.6 and 3.5 per 100,000) (National Center for Injury Prevention and Control [NCIPC], 2007). In fact, the suicide rates are higher for men throughout the life span and the gender gap widens considerably after age 75 (NCIPC, 2007). Fortunately, the suicide rate for adolescent males decreased from 1994 to 2004. Yet the rates of suicide are still high among non-Hispanic American Indian/Alaskan Native and White male adolescents (see Figure 1). Both sexes attempt suicide, but adolescent females make more attempts than males. The literature consistently states that male adolescents are much more likely to use more lethal methods to commit suicide (see Figure 2) but adolescent females who complete suicide, also use lethal methods (e.g., firearms and suffocation). The reason for this has not been studied extensively in the United States, but research on adult men in Europe suggests that men have more conduct problems, misuse drugs/alcohol, form poor social support networks, talk less about feelings, believe they should be in control of their lives and are more action oriented, and thus use more lethal suicide methods (Bridge, 2006; Brownhill et al., 2005; Grant et al., 2002; Hawton & James, 2005). Same-sex orientation is associated with higher risk for suicidal thoughts and suicide attempts (Russell & Joyner, 2001). The use of firearms has decreased over the past decade (NCIPC, 2007). Suicide by suffocation has increased slightly during the same period and now accounts for more than one third of all suicidal deaths among 15- to 19-year-olds (NCIPC, 2007). Suicide among male adolescents is still a major public health problem.

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Table 2. Practice Parameters for the Assessment and Treatment of Children and Adolescents With Depressive Disorders
Gather information from multiple sources, including parents/ caregivers. Contact is often required with other sources, such as teachers, social services professionals, or a current mental health clinician if involved. Assess comorbidity, psychosocial and academic problems, psychiatric family history, social support, medical and medications history, substance abuse (including nicotine use), and early and recent negative life events (including physical and sexual abuse). Perform a developmentally appropriate mental status examination. Be aware that teens can be difficult to engage and are frequently irritable and uncooperative. Using the DSM-IV criteria as a guide, teens should be asked about their depressive symptoms and the time course. Suicide risk must be assessed. Questions about hypomania and mania are important. They should be asked about psychotic symptoms and delusions, anxiety, symptoms of attention deficit and hyperactivity disorder, and substance use, all of which are frequently comorbid. Be alert to ethnic and cultural factors that may influence the presentation of symptoms and the approach to treatment. Assess level of functional impairment, which guides treatment recommendations. Source: Adapted from Birmaher, Brent, and Benson (1998).

Suffocation 37.2% Firearms 51.2%

Poisoning 5.2% Fall 2.1% Others 4.3%

Figure 2.

Causes of Suicide, Males Ages 15-19, 2004

Risk Factors for Depression

Research has identified several factors, both biomedical and psychosocial, that put both male and female adolescents at greater risk for depression. Depression is moderately heritable, with a family history of depression identified in 20% to 50% of children and adolescents who experience depression (Jackson & Lurie, 2006). Adolescents with certain chronic illnessesfor example, diabetesare at higher risk for depression (Bhatia & Bhatia, 2007). Previous history of depression and other comorbid psychiatric disorders are also risk factors (Bhatia & Bhatia, 2007; Rushton et al., 2002). In fact, there is significant evidence that many of the comorbid psychotic disorders such as conduct disorder and addictive disorders precede the depression (Kessler & Walters, 1998). Smoking has been connected to the development of depression via the effects of nicotine on the central nervous system. Conversely, depressed adolescents are more likely to initiate smoking (Jackson & Lurie, 2006). Adolescents who experienced a past year MDE were more than twice as likely to have smoked cigarettes during the past month as those without a past year MDE (SAMHSA, 2005). Family environmental factors such as family conflict, low socioeconomic status, and the death of a parent or loved one can increase development of depression (Evans

et al., 2005; Jackson & Lurie, 2006). Clinicians must be cognizant of these risk factors when caring for this population of adolescents.

The Critical Role of the Primary Care Clinician

Treating adolescent depression in the primary care setting is realistic, efficacious, and feasible (Stein, Zitner, & Jensen, 2006). Supportive interventions and active problem-solving with health care professionals may be beneficial, particularly when adolescents are unable to get care outside the primary care setting (Stein et al., 2006). It is important for the primary care clinician (PCC) to have skills to identify depression and provide treatment and referral to a mental health specialist, as appropriate. Unfortunately, there is a shortage of child and adolescent psychiatrists in certain geographic areas, which makes PCCs essential in providing needed care (Evans et al., 2005; Stein et al., 2006; Zuckerbrot & Jensen, 2006). Most uncomplicated cases of adolescent depression (initial episode or recent onset in

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the absence of coexisting conditions) can be managed by the primary care clinician if they have adequate training, experience, and access to consultative support (Brent & Birmaher, 2002). The PCC must educate adolescents and family about the limitations of confidential information and take advantage of the opportunity to recognize adolescent depression early, using various screening self-reporting tools, and become more comfortable with management guidelines to treat and monitor adolescent depression.

Referral and Management

There are four key components to the initiation of treatment of adolescent depression before the clinician can embark on the various referral and management options:
1. Patient/family education: Education of the patient and family should focus on depression as an illness and its symptomatology (Brent & Birmaher, 2002; Jackson & Lurie, 2006). Describing depression in terms of a medical illness like asthma may help the patient/family understand the seriousness of the problem and need for treatment. In fact, adolescents are often relieved that depression is common and considered a medical illness and is not a reflection of a weak character (Jackson & Lurie, 2006). 2. Identify/mitigate hopelessness: Identifying and mitigating hopelessness, which is linked to withdrawal from treatment and suicidal behavior, can be accomplished in part through education and discussion of expectations of treatment (Brent & Birmaher, 2002). 3. Create a no-suicide contract: A no-suicide contract should be established to form an oral and written agreement if and when suicidal ideation is to be handled (Brent & Birmaher, 2002). This form of safety contract used alone is not adequate to prevent suicide (Jackson & Lurie, 2006) but can often test the ability of the patient and family to problem-solve and form a therapeutic relationship with the treating clinician (Brent & Birmaher, 2002). 4. Remove all firearms from the home: Remove all firearms from the home because their presence is a risk factor for suicide (Brent & Birmaher, 2002). This is especially true for depressed male adolescents.

Assessment
The PCC has a key role in identifying adolescents with depression. Adolescents visit their PCC at least two to three times a year and can report mental health concerns to these providers (Bernal et al., 2000; Horwitz et al., 2002). There are three crucial areas of evaluation that must be covered: building a therapeutic alliance with the teenager and family, performing a good diagnostic assessment, and evaluating for suicidal risk (Jackson & Lurie, 2006). The American Academy of Child and Adolescent Psychiatry (AACAP) has specific guidelines for the evaluation of depressed adolescents (Birmaher, Brent, & Benson, 1998), yet these guidelines may be hard to achieve in a busy primary care practice (see Table 2). Complicating the PCCs role in delivering mental health care is the fact that PCCs are often not reimbursed for mental health services (Stein et al., 2006). Researchers have evaluated various screening tools that can be used in the primary care setting to help identify those at risk for depression. A literature review by Zukerbrot and Jensen identified that adolescent self-report tools that use recommended clinical cutoff scores identify more patients with depression than other methods (e.g., standard interview using mnemonics) (Zuckerbrot & Jensen, 2006). The Beck Depression Inventory for Primary Care was reported to be useful in screening predominately healthy adolescents (Winter, Steer, Jones-Hicks, & Beck, 1999). Brent and Birmaher suggested that the PCC make assessments in the following areas: suicidal ideation with intent, access to lethal agents, possibility of medical illnesses with similar presentations, patients personal and family history, and patient home environment (Brent & Birmaher, 2002).

Treatment options should include psychotherapy and medication management while addressing academic issues, social skills, and family functioning (Jackson & Lurie, 2006). Cognitive behavioral therapy (CBT) over a period of 3 to 4 months and interpersonal therapy have been shown to be efficacious for adolescent depression (Brent & Birmaher, 2002). If there is no response to psychotherapy in 6 to 8 weeks or moderate to severe depression exists (Jackson & Lurie, 2006), accepted guidelines recommend adding a selective serotonin reuptake inhibitor (SSRI) to the

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treatment regimen (Brent & Birmaher, 2002; Jackson & Lurie, 2006). Although the complete pharmacologic prescribing guideline for teens is beyond the scope of this article, fluoxetine is the only SSRI with a U.S. Food and Drug Administration (FDA) indication for treatment of depression in adolescents (Jackson & Lurie, 2006). Once clinical response is achieved, treatment should continue for 6 months to 1 year to reduce the risk of relapse (Birmaher et al., 1998; Brent & Birmaher, 2002; Jackson & Lurie, 2006). Controversy has surrounded the use of SSRIs by adolescents since a meta-analysis done by the FDA reported suicide-related events (ideation or preparation or attempt) occurred in 2% of patients on placebo and 4% of patients on medication (FDA, 2004). In October 2004, the FDA issued a black box warning regarding the risk for suicidality in children and adolescents who are being treated with antidepressants. Secondary to the warning, clinicians must ensure close follow-up with adolescent patients started on SSRI medication (FDA recommends weekly visits in the first 4 weeks vs. the AACAP, which recommends visits 2 to 3 weeks after initiation) (Jackson & Lurie, 2006). Monitoring guides are available for both clinicians (Ferren, 2006) and parents on the World Wide Web (ParentsMedGuide.org, 2007; American Academy of Pediatrics, 2007). A potential backlash of the black box warning was a drop in primary clinicians prescribing antidepressants to adolescents, and early evidence that suicides increased by 14% between 2003 and 2004 (Gibbons et al., 2007). The Treatment for Adolescents With Depression Study recently reported that the use of fluoxetine alone or in combination with CBT accelerates the treatment process and CBT enhances the safety of the antidepressant medication (The Treatment for Adolescents With Depression Study, 2007). Discussion of the limitations of the original FDA meta-analysis is beyond the scope of this article, but a recent meta-analysis by Bridge et al. identified that the benefits of antidepressants appear to be much greater than risk from suicidal ideation/attempts (Bridge et al., 2007; Lock, Walker, Rickert, & Katzman, 2005).

Access to Mental Health Services

For all adolescents, identification and treatment of depression depends in large part on access to health
2. At time of writing, President Bush had just vetoed a bill reauthorizing funding for the State Childrens Health Insurance Program.

care services. Many primary care clinicians may not follow guidelines related to adolescent depression for reasons including lack of awareness, skills, or time. For those who do follow guidelines, the lack of adolescent mental health specialists makes it difficult for PCCs to provide needed referrals. In addition, adolescents encounter many financial barriers to services. In a 2006 review article, Kapphahn et al. examined several factors that influence access, including insurance status, mental health parity and other legislation, and managed care arrangements that carve out mental health services to a system separate from the system providing physical health services (Kapphahn, Morreale, Rickert, & Walker, 2006). These carve-outs, identified in both public and private insurance, often preclude reimbursement for even an initial assessment and referral from a PCC. Thus, adolescents and their families must navigate the system to get needed care with limited guidance from a PCC. Insured adolescents have more access to mental health care than the uninsured, according to Kapphahn et al. (2006). In 2002, 87.8% of adolescents had fullyear insurance, 65.1% had private insurance, primarily employer-sponsored; 21.5% had public insurance; and a small 1.3% had both public and private coverage (Newacheck, Park, Brindis, Biehl, & Irwin, 2004). However, insurance frequently does not cover recommended services for depression, especially outpatient mental health services. The two primary sources of publicly funded insurance, Medicaid and the State Childrens Health Insurance Program (SCHIP)2 differ in their coverage. Medicaid requires that children and adolescents receive any medically necessary services to rectify problems uncovered in a screen. However, suboptimal screening rates mean that problems remain unidentified and untreated (Kapphahn et al., 2006). In creating SCHIP programs, states can either expand Medicaid regulations or create stand-alone programs. Most states with stand-alone programs limit outpatient mental health services to 20 to 30 days per year; a few cover 60 days (Kenny, Oliver, & Poppe, 2002). A 2003 analysis of major private insurance plans in 48 states found that only 55% of plans would cover all needed services for depression. Although most plans examined would cover acute and well care visits with a PCC and recommended prescription drugs, few offered adequate coverage of outpatient mental health services. Either these services were not covered or, more frequently, plans included language restricting the number of visits (Fox, McManus, & Reichman, 2003). Finally, safety net programs, funded by federal, state, and local governments, aim to finance mental health services for those who lack coverage for mental

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health services. About 20% of financing for child and adolescent mental health care services comes from state and local sources other than insurance programs (Van Landeghem & Hess, 2005). To address the shortcomings in private insurance coverage of mental health services, federal and state governments have enacted parity laws to make coverage of mental health services equal to physical health services. These laws have limited impact. Federal parity laws, for example, do not apply to co-pays and deductibles and only apply to plans that offer coverage for mental health services. Almost all states have passed laws to improve access to mental health services, such as parity laws and mandated coverage of certain services. However, due to federal law, companies that self-insure (i.e., assume the risk of insurance) are exempt from state insurance mandates. Thus, state laws have limited impact (Kapphahn et al., 2006). Clearly, adolescents needing services for depression face a fragmented mental health care system, given the patchwork of public insurance and safety net programs, federal laws, and disparities in private plans coverage of mental health services. Many states and local governments have developed programs to improve systems of mental health care by coordinating funding streams and integrating services. Funding for these initiatives come from federal, state, and local sources (Kenny et al., 2002).

Health Resources and Services Administration, U.S. Department of Health and Human Services (U45MC 00002 & T71MC00003). The authors would like to thank Charles E. Irwin Jr., MD, for a review of an earlier draft of this article and Tina Paul Mulye, MPH, for editorial assistance in the preparation of this manuscript.

References
American Academy of Pediatrics. (2007). Childrens mental health in primary care. Retrieved October 3, 2007, from http://www.aap.org/mentalhealth American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: R. R. Ponneley. Bernal, P., Estroff, D. B., Aboudarham, J. F., Murphy, M., Keller, A., & Jellinek, M. S. (2000). Psychosocial morbidity: The economic burden in a pediatric health maintenance organization sample. Archives of Pediatric and Adolescent Medicine, 154(3), 261-266. Bhatia, S. K., & Bhatia, S. C. (2007). Childhood and adolescent depression. American Family Physician, 75(1), 73-80. Birmaher, B., Brent, D. A., & Benson, R. S. (1998). Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 37(11), 1234-1238. Brent, D. A., & Birmaher, B. (2002). Clinical practice. Adolescent depression. New England Journal of Medicine, 347(9), 667-671. Bridge, J. A., Iyengar, S., Salary, C. B., Barbe, R. P., Birmaher, B., Pincus, H. A., et al. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. Journal of the American Medical Association, 297(15), 1683-1696. Bridge, S. (2006). Suicide preventionTargeting the patient at risk. Australian Family Physician, 35(5), 335-338. Brownhill, S., Wilhelm, K., Barclay, L., & Schmied, V. (2005). Big build: Hidden depression in men. Australian and New Zealand Journal of Psychiatry, 39(10), 921-931. Evans, D. L., Beardslee, W., Biederman, J., Brent, D., Charney, D., Coyle, J., et al. (2005). Defining depression and bipolar disorder. In: D. L. Evans et al, eds. Treating and preventing adolescent mental health disorders, what we know and what we dont know (pp. 4-27). New York: Oxford University Press. Ferren, P. M. (2006). Demystifying the black box warning on antidepressants: A protocol for safe prescribing in your practice. Contemporary Pediatrics, 23(2), 28-35. Fox, H. B., McManus, M. A., & Reichman, M. B. (2003). Private health insurance for adolescents: Is it adequate? Journal of Adolescent Health, 32S, 12-24. Gibbons, R. D., Brown, C. H., Hur, K., Marcus, S. M., Bhaumik, D. K., Erkens, J. A., et al. (2007). Early evidence

Conclusion
Adolescent depression and suicide is a major public health problem, especially for adolescent males, in terms of morbidity and mortality. Male adolescents with depression may be underdiagnosed because of gender differences in presentation of depressive symptoms. Primary care clinicians are often the first to identify a depressed adolescent. Therefore, it is imperative for them to build a therapeutic alliance with the teen and family, perform a good diagnostic assessment using evidence-based screening tools, and evaluate suicide risk. Until there are significant changes in mental health access, clinicians must increase their knowledge of antidepressant medication and foster partnerships with child and adolescent mental health providers.

Acknowledgments
The development of this article was supported in part by grants from the Maternal and Child Health Bureau,

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