Age-Related Depression, Mood and Stress

Depression rates growing among adolescents, particularly girls

Age-Related Depression, Mood and Stress | Johns Hopkins Medicine

The rate of adolescents reporting a recent b clinical depression grew by 37 percent over the decade ending in 2014, with one in six girls reporting an episode in the past year, new Johns Hopkins Bloomberg School of Public Health-led research suggests.

The findings, published online Nov. 14 in the journal Pediatrics, highlight a need to focus on the mental well-being of young people and match those in peril with mental health professionals.

“This shows us there are a growing number of untreated adolescents with depression and that we are making few inroads in getting mental health care to this population,” says study leader Ramin Mojtabai, MD, PhD, MPH, a professor in the Department of Mental Health at the Bloomberg School. “It is imperative that we find ways to reach these teenagers and help them manage their depression.”

Suicide rates have been increasing in recent years, particularly among adolescent girls and young women. The Centers for Disease Control and Prevention this month reported that suicide rates among American middle school students — those aged 10 to 14 — were higher than rates of death from motor vehicle crashes in that age group.

For the study, the researchers analyzed data from the 2005 to 2014 National Surveys on Drug Use and Health on adolescents and young adults to examine trends in “major depressive episodes” over the previous year.

Major depressive episodes, also known as clinical depression, occur when someone develops a depressed mood or a loss of interest or pleasure in daily activities along with other depressive symptoms consistently for at least two weeks.

Overall, 176,245 adolescents aged 12 to 17 and 180,459 adults aged 18 to 25 were involved in the annual study between 2005 and 2014.

Participants were told about symptoms of depression and were asked whether they had experienced them in the prior year. In 2005, 8.7 percent of adolescents reported major depressive episodes in the past year; the figure was 11.

3 percent in 2014. The percentage had remained relatively steady from 2005 to 2011, but grew from 2012 through 2014.

Among girls, the prevalence of major depressive episodes increased from 13.1 percent in 2005 to 17.3 percent in 2014. White adolescents and young adults were also more ly than non-whites to experience these episodes. Among young adults, the prevalence of these episodes grew from 8.8 percent in 2005 to 9.6 percent in 2014, though the increase was only found in those ages 18 to 20.

The findings were ly on self-reporting, not on clinical diagnoses. The researchers controlled for substance abuse and socioeconomic factors.

There were few significant changes in the use of mental health treatment among those adolescents and young adults with depression.

In adolescents, after 2011, there were small increases in visits to specialty mental health providers, the use of inpatient and day treatment centers and medication.

These increases, however, were not enough to keep up with the increases in those with clinical depression.

The increase in some treatment could be related to the expansion of health insurance under the Affordable Care Act and mental health parity legislation, though the future of health insurance expansion is in jeopardy following the recent election of a new U.S. President.

The researchers say it is unclear what is driving the rise in major depressive episodes, particularly among girls. They say adolescent girls may have been exposed to a greater degree of depression risk factors in recent years.

Cyberbullying, for example, may have increased more in girls, as studies have shown that they use mobile phones more frequently and intensively than boys and problematic mobile phone use among young people has been linked to depressed mood.

The results coincided with a major economic downturn, however, there has not been an increase in the prevalence of clinical depression among adults over the period and this study found no increase among those age 21 to 25.

“The growing number of depressed adolescents and young adults who do not receive any mental health treatment calls for renewed outreach efforts, especially in school and college health centers, counseling services and pediatric practices, where many of the untreated adolescents and adults with depression may be detected and managed,” Mojtabai says.

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Materials provided by Johns Hopkins Bloomberg School of Public Health. Note: Content may be edited for style and length.


Adjustment Disorder | Johns Hopkins Psychiatry Guide

Age-Related Depression, Mood and Stress | Johns Hopkins Medicine

  • Persistent maladaptive emotional or behavioral reaction within several months of an identifiable stressful event or change in a person’s life
  • Prevalence in primary care ranges from 3-10%, and frequently is undiagnosed by general practitioners.[1][2]
  • Prevalence in patients in outpatient mental health treatment ranges from 5-20%.
  • Prevalence in a hospital psychiatric consultation setting frequently reaches 50% or higher.[3]
  • Common in children and adolescents, where the response tends to be behavioral (acting out) rather than emotional (e.g., low mood)[4]
  • Equally prevalent in males and females
  • Variable in course and manifestations across cultures
  • The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature.
    • These symptoms are proportion to the severity or intensity of the stressor (taking into account the external context and the cultural factors that might influence symptom severity and presentation).
    • This leads to impairment in social, occupational, or other important areas of functioning.
    • Patient may have depressed mood, anxiety, or maladaptive behaviors, but does not have a cluster of symptoms that meet criteria for another mental disorder.
  • The stressor may be a single event (e.g., termination of a romantic relationship, diagnosis with a disabling or life-threatening medical condition), or there may be multiple stressors (e.g.

    , marked business difficulties and marital problems).

  • Stressors may be recurrent (e.g., seasonal business crises, unfulfilling sexual relationships, recurrent hospitalizations for a medical illness) or continuous (e.g., a persistent painful illness with increasing disability, living in a crime-ridden neighborhood).

  • Stressors may affect a single individual, an entire family, or a larger group or community (e.g., a natural disaster).
  • Some stressors may accompany specific developmental events (e.g., going to school, leaving or returning to the parental home, getting married, becoming a parent, failing to attain occupational goals, developing age-related medical ailments, retirement).
  • May be diagnosed following the death of a loved one when the intensity, quality, or persistence of grief reactions exceeds what normally might be expected, when cultural, religious, or age-appropriate norms are taken into account
  • Associated with an increased risk of suicide attempts and completed suicide
  • Development and Course
    • By definition, the disturbance in adjustment disorders begins within 3 months of onset of a stressor and lasts no longer than 6 months after the stressor or its consequences have ceased.
    • If the stressor is an acute event (e.g., being fired from a job), the onset of the disturbance tends to be immediate (i.e., within a few days) but for a relatively brief duration.
    • If the stressor persists, the reaction to stress may persist as well.
  • Adjustment disorder is a clinical diagnosis history and mental status examination, without a diagnostic laboratory test.
  • Tests to rule out medical illnesses include CBC, BMP, LFTs, TSH, B12, folate, vitamin D, RPR, blood alcohol level, urinalysis, urine toxicology.
  • Major depressive disorder
  • Bipolar disorder
  • Persistent depressive disorder (dysthymia)
  • Posttraumatic stress disorder
  • Acute stress disorder
  • Personality disorders
  • Normative stress reactions
  • Grief
  • Psychological factors affecting other medical conditions
    • This refers to psychological symptoms and behaviors that may exacerbate a medical condition (put the patient at risk for medical illness or worsen an existing condition).
    • In contrast, an adjustment disorder is a reaction to the stressor (i.e., having the medical illness).
  • The main goals of treatment are symptom relief/cessation of disturbed conduct and restoration to baseline function (or better).
  • Medications are generally not indicated to alleviate adjustment disorder, though they may alleviate some specific accompanying symptoms.
    • However, physicians should be especially careful of over-prescribing medications for symptoms of mild to moderate situational anxiety or depression, as symptom suppression may diminish the capacity or incentive to adjust to or change problematic situations.
  • Psychotherapy is the treatment of choice for demoralization and adjustment disorders. The form of psychotherapy will vary from patient to patient and from clinician to clinician, including supportive coaching to address life stressors, behavioral approaches to remodel maladaptive habits, and insight-oriented approaches to strengthen psychic defenses.
  • Some individuals may also benefit from family therapy, especially if the situation is family-related or the patient is an adolescent.
  • Couples therapy may also be appropriate when the disorder is negatively affecting a romantic relationship.
  • Demoralized patients may exhibit a rapid apparent recovery after initiating treatment, stimulated by the prospect of psychotherapeutic relief, without also undergoing a significant change in attitude or situation. A full, planned course of a time-limited therapy, or additional visits after the symptoms have resolved, may help ensure continued resolution.
  1. Fernández A, Mendive JM, Salvador-Carulla L, et al. Adjustment disorders in primary care: prevalence, recognition and use of services. Br J Psychiatry. 2012;201:137-42.  [PMID:22576725]
  2. Sundquist J, Ohlsson H, Sundquist K, et al. Common adult psychiatric disorders in Swedish primary care where most mental health patients are treated. BMC Psychiatry. 2017;17(1):235.  [PMID:28666429]
  3. Popkin MK, Callies AL, Colón EA, et al. Adjustment disorders in medically ill inpatients referred for consultation in a university hospital. Psychosomatics. 1990;31(4):410-4.  [PMID:2247569]
  4. Portzky G, Audenaert K, van Heeringen K. Adjustment disorder and the course of the suicidal process in adolescents. J Affect Disord. 2005;87(2-3):265-70.  [PMID:16005078]
  5. American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  6. Casey P, Maracy M, Kelly BD, et al. Can adjustment disorder and depressive episode be distinguished? Results from ODIN. J Affect Disord. 2006;92(2-3):291-7.  [PMID:16515807]
  7. Strain JJ, Smith GC, Hammer JS, et al. Adjustment disorder: a multisite study of its utilization and interventions in the consultation-liaison psychiatry setting. Gen Hosp Psychiatry. 1998;20(3):139-49.  [PMID:9650031]
  8. Strain JJ, Friedman MJ. Considering adjustment disorders as stress response syndromes for DSM-5. Depress Anxiety. 2011;28(9):818-23.  [PMID:21254314]

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Expanding Our Definition of Diversity : Johns Hopkins Center for Innovative Medicine

Age-Related Depression, Mood and Stress | Johns Hopkins Medicine

Johns Hopkins psychologist Kay Redfield Jamison, the Dalio Professor of Mood Disorders, has forged an influential career by thinking outside the box.

The recipient of a MacArthur “Genius Grant,” she’s written several well-received books that offer thought-provoking ideas about the links between creativity and mental illness – most recently one about American poet Robert Lowell (see accompanying story).

As someone who has lived with manic depression (bipolar disorder) since early in her academic career – she was diagnosed soon after joining the UCLA faculty as an assistant professor in the early 1970s – Jamison knows firsthand the challenges the illness can present. But, she points out, there are also positives.

And it’s precisely these positives that have led to her latest outside-the-box idea, which she shared in early October at the Center for Innovative Medicine Board Retreat. “When it comes to medical school admissions, people with mental illness are pretty much ruled out, and this has had real consequences,” she says.

“We are excluding people from the field of medicine who have some very interesting ways of thinking.”

“If we want to achieve true diversity in medicine,” Jamison says, “we must begin talking about ways to identify and admit people with mental illness to medical school.”

“When it comes to medical school admissions, people with mental illness are pretty much ruled out, and this has had real consequences. We are excluding people from the field of medicine who have some very interesting ways of thinking.” – Kay Redfield Jamison

There are certain kinds of temperaments, Jamison goes on to explain, that are more frequently associated with bipolar disorder and depression. “People with these illnesses often have a fiery curiosity.

They are risk takers. And in academic medicine, we need this kind of temperament: People who are willing to take risks, both intellectually and scientifically.

People who are willing to push the envelope by asking new questions.”

In addition, and crucially important to the goal of good doctoring: Those with mental illness have a deep understanding of what it’s to live with suffering. “They learn from this suffering and can bring it into their work with patients,” she says.

But under the current medical school admissions system, there is no systematic effort to identify and attract candidates with mental illness. In fact, the system is set up to exclude them, Jamison says.

“If you’ve taken a semester or two off for hospitalization for treatment for bipolar disorder, you almost certainly won’t be considered,” she says, “which is unfortunate since these are relatively common illnesses and they are very treatable.”

“We need to seriously start talking about this, and to expand our definition of ‘diversity’ in medical school admissions to include people with mental illness.” – Kay Redfield Jamison

While conceding that there are no “easy answers” for changing the current system, Jamison would at least to get the conversation started, perhaps with a national summit meeting right here at the Center for Innovative Medicine at Johns Hopkins.

“We need to seriously start talking about this,” says Jamison, “and to expand our definition of ‘diversity’ in medical school admissions to include people with mental illness.”

Taking the Ache Away
Kay Redfield Jamison found a rapt audience when she delivered the 2017 annual Miller Lecture in May.

The focus of her talk was powerful indeed: the experience of “losing your mind”– and the important relationship between doctor and patient that is needed for true healing.

Calling on insights shared in her most recent book, Robert Lowell: Setting the River on Fire, she also examined the restorative role that writing has played for writers and poets ( Lowell) who have struggled with mental illness.

Jamison, who is the Dalio Professor of Mood Disorders at Johns Hopkins, noted that manic depression, or “mania,” was described long before Hippocrates as a sort of “burning passion” or “ferocity without fever.” While flowers and herbs were used to treat mania in the 1500s, methods grew much less humane by the 1700s.

As evidence, she shared disturbing images of shackles and chains, and a close-topped iron “restraining crib” – tools commonly used during that time to control those in the throes of mania.

Fortunately, treatments improved over the ensuing centuries and today include medications (such as lithium, anticonvulsants and antipsychotics), electroconvulsive therapy and psychotherapy.

It is this last, psychotherapy, that proved critically important in the wake of World War I for soldiers beset by “shell shock” from what they’d experienced on the battlefield.

“They had, quite literally, lost their minds,” notes Jamison. Into the breach jumped Dr. W.H.R. Rivers, a British psychiatrist (he founded the British Journal of Psychology), who specialized in treating such soldiers.

Among his patients was Siegfried Sassoon, one of the period’s great poets.

The two developed a close doctor/patient bond that proved critical to Sassoon’s ultimate healing. Rivers explained his approach to psychotherapy this way: “The doctor should make intolerable memories tolerable; he should use the controlled reflection of horror to understand what the patient has been through, to allow him to meet the horror in his own strength.”

Jamison underscored for her listeners that when it comes to mental illness, “there’s a difference between treatment and healing. Healing requires patients to be actively involved, and it demands an almost mystical relationship between patient and doctor.”

Fast forward 30 years to the rise of Lowell as one of America’s leading postwar poets. Lowell struggled with manic depression all his life. Frequently hospitalized, subjected to electric shock, and later heavily medicated with chlorpromazine and lithium, Lowell lived through periods of exultant mania and ensuing deep depression, notes Jamison.

Sassoon, Lowell used writing as a way to distance himself from the horror he experienced. “Writing fell to me a life preserver,” he told one doctor in the mid-1950s. And in a 1976 letter to a friend, he penned, “How often writing takes the ache away.”

“Writing heals,” affirmed Jamison, to those assembled for the Miller Lecture: “Writing brings structure to disorder, provides escape and mastery, gives vocation and salvation, and resurrects and renews.”

Lowell appears to have welcomed the earliest stirrings of oncoming mania as much as he dreaded them. As Jamison notes in her book, the words and ideas mania revealed were a creative trove. “I write my best poetry when I’m manic,” he once professed. Later he wrote: “Darkness honestly lived through is a place of wonder and life. So much has come from there.”


Depression: What You Need to Know as You Age

Age-Related Depression, Mood and Stress | Johns Hopkins Medicine

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If you’re one of the more than 14.

8 million American adults who experiences major depression, you may feel so bad that you can’t get bed, be around the people you love or participate in activities that you usually enjoy.

Actually, there are more than 50 different symptoms of major depression, ranging from the well-known—crying and sadness—to those you might never associate with depression, such as anger, workaholism and back pain.

Depression is a disease that affects every aspect of a person’s life, not just mood, says Johns Hopkins expert Andrew Angelino, M.D., Chair of Psychiatry at Howard County General Hospital. The World Health Organization predicts that by 2020, depression will be the second-leading cause of disability in the world, just behind cardiovascular disease.

People who are depressed are far more ly to have other chronic medical conditions, including cardiovascular disease, back problems, arthritis, diabetes, and high blood pressure, and to have worse outcomes. Untreated depression can even affect your immune response to some vaccines.

Depression is not just debilitating; it can be deadly. An estimated one five people with depression will attempt suicide at some point.

Depression is not a mood you can just get over. It is a disease in which the brain ceases to register pleasurable activities, says Angelino. Indeed, MRI studies with depressed people have found changes in the parts of the brain that play a significant role in depression.

Women are about twice as ly as men to be diagnosed with depression. You’re also more ly to develop depression if you are between ages 45 and 64, nonwhite, or divorced, and if you never graduated high school, can’t work or are unemployed, and don’t have health insurance. Other risks for depression include factors such as these:

  • Experiencing stressful events in your life, such as losing your job, having problems in your marriage, major health problems, and/or financial challenges.
  • Having a bad childhood, such as one involving abuse, poor relationships with your parents, and/or your parents own marital problems.
  • Certain personality traits, such as getting extremely upset when you’re stressed.
  • A family history of depression, which can increase your own risk three or four times.

Depression is far more common than you might think, with nearly one 10 adults depressed at any time, about half of them severely.

Symptoms of depression vary widely but can be divided into three main categories:

  • Emotional and cognitive (thinking) symptoms include a depressed mood, lack of interest or motivation in things you typically enjoy, problems making decisions, irritability, excessive worrying, memory problems and excessive guilt.
  • Physical symptoms include fatigue, sleep problems (such as waking too early, problems falling or staying asleep, sleeping too much), changes in appetite, weight loss or gain, aches and pains, headaches, heart palpitations, and burning or tingling sensations.
  • Behavioral symptoms include crying uncontrollably, having angry outbursts, withdrawing from friends and family, becoming a workaholic, abusing alcohol or drugs, cutting or otherwise hurting yourself, and, in the worst cases, considering or attempting suicide.

Depression can be classified as:

  • Major depressive disorder (MDD), which includes depressed mood and/or reduced interest and pleasure in life, considered “core” symptoms, and other symptoms that significantly affect daily life.
  • Dysthymia, (dis-THI-me-a), a milder form of depression that can progress to MDD.
  • Postpartum depression, which occurs within weeks of giving birth.
  • Psychotic depression, which comes with delusions and/or hallucinations.
  • Seasonal affective depression, which occurs as the days get shorter and improves with spring.

Johns Hopkins researcher Vikram S. Chib studies the way incentives and rewards work in the brain and how this can lead to breakthroughs in depression treatment.

Cardiovascular (car-dee-oh-vas-cue-ler) disease: Problems of the heart or blood vessels, often caused by atherosclerosis—the build-up of fat deposits in artery walls—and by high blood pressure, which can weaken blood vessels, encourage atherosclerosis and make arteries stiff. Heart valve disorders, heart failure and off-beat heart rhythms (called arrhythmias) are also types of cardiovascular disease.

Cognitive behavioral therapy (CBT): Two different psychotherapies—cognitive therapy and behavioral therapy— in one. Cognitive therapy can help you improve your mood by changing unhelpful thinking patterns.

Behavioral therapy helps you identify and solve unhealthy habits.

When used in conjunction with each another, these therapies have been shown to improve problems such as depression, anxiety, bipolar disorder, insomnia and eating disorders.

Heart palpitations (pal-peh-tay-shuns): The feeling that your heart is thumping, racing, flip-flopping or skipping beats.

Strong emotions, caffeine, nicotine, vigorous exercise, medical conditions (such as low blood sugar or dehydration) and some medications may cause heart palpitations.

Call 911 if you also have chest pain, shortness of breath or unusual sweating, or feel dizzy or faint.

Immune response: How your immune system recognizes and defends itself against bacteria, viruses, toxins and other harmful substances. A response can include anything from coughing and sneezing to an increase in white blood cells, which attack foreign substances.

Interpersonal therapy (IPT): A treatment often used for depression that lifts mood by teaching you how to relate with others in a healthier way. A therapist will help you identify troubling emotions and their triggers, express emotions in a more productive way and examine past relationships that may have contributed to your current mental health issues.

Lean protein: Meats and other protein-rich foods low in saturated fat. These include boneless skinless chicken and turkey, extra-lean ground beef, beans, fat-free yogurt, seafood, tofu, tempeh and lean cuts of red meat, such as round steaks and roasts, top loin and top sirloin. Choosing these can help control cholesterol.

Omega-3 fatty acids (oh-may-ga three fah-tee a-sids): Healthy polyunsaturated fats that the body uses to build brain-cell membranes.

They’re considered essential fats because our body needs them but can’t make them on its own; we must take them in through food or supplements.

A diet rich in omega-3s—found in fatty fish, salmon, tuna and mackerel, as well as in walnuts, flaxseed and canola oil—and low in saturated fats may help protect against heart disease, stroke, cancer and inflammatory bowel disease.

Whole grains: Grains such as whole wheat, brown rice and barley still have their fiber-rich outer shell, called the bran, and inner germ. It provides vitamins, minerals and good fats. Choosing whole grain side dishes, cereals, breads and more may lower the risk for heart disease, type 2 diabetes and cancer and improve digestion, too.


Coping With Depression: A Guide to Good Treatment

Age-Related Depression, Mood and Stress | Johns Hopkins Medicine

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