Depression and Obesity in Adolescents

Depression and Obesity in Adolescents What Can Primary Care Providers Do? Christina J. Calamaro and Roberta Waite ABSTRACT The health effects of childhood obesity have been shown to have serious short- and longterm consequences that include a wide range of psychological and physical ailments. In particular, obesity and depression, conditions once considered only adult health problems, are increasing in adolescents.There is some early evidence suggesting that predictors of depression such as shortened sleep, sedentary behavior, and depressed mood, may overlap as predictors of obesity. Assessment, evaluation, and treatment of these predictors could lead to better strategies for the primary care provider to not only manage and treat the depression, but potentially prevent and better manage the coexisting obesity and prevent further complications. Keywords: adolescence, comorbidity, depression in the adolescent, pediatric obesity INTRODUCTION Obesity and depression, conditions once considered adult health problems, are increasing in prevalence among children and adolescents.The increased prevalence of obesity (defined as body mass index [BMI] > 95th percentile for age and-gender1) in youth is now seen as a public health crisis, and if unchecked, it is predicted that 24% of American children will be overweight or obese by 2015.2 The health effects of childhood obesity have been shown to have serious short- and longterm consequences, which include a wide range of psywww.npjournal.org

chological and physical ailments (eg, low self-esteem, depression, anxiety, type 2 diabetes, hypertension, hyperlipidemia, polycystic ovarian syndrome, asthma, and obstructive sleep apnea).3 Adolescence (defined as children ages 12 to 18 years)4 is a period of life wherein puberty is a primary neurohormonal determinant of physiologic and psychological changes that occur. Social and behavioral factors can also contribute to the process of puberty. During this period, weight gain and depression can become more common, indicating the likelihood of The Journal for Nurse Practitioners - JNP

255

simultaneous occurrence, as well as the likelihood of a and discrimination against individuals with obesity prepossible association.5 vail.These individuals are described as “ugly, unhappy, Primary health care providers are cognizant of the less competent, socially isolated, and lacking in self-disphysiological implications of obesity among adolescents. cipline, motivation and personal control” (p. 1802).14 However, the psychosocial issues associated with adolesEvidence is even emerging that both children and cent obesity are not well understood and quite often are adults implicitly believe that obese individuals are more neglected.6 Given the toll that both disorders have on likely to be carrying communicable pathogens than are adolescents’ quality of life and functional status, it is non-obese individuals.15,16 important to explore the link between them and target Gender issues are also identified in association with interventions that primary care providers (PCPs) can use weight and mental health issues. As early as age 5, chilto mitigate adverse consequences. Considering the numdren rate overweight and obese children as less likeable, ber of moderating and mediating particularly obese female chilvariables that relate to both dren.17 Biases such as this depression and obesity during appear to persist into the the developmental period of female’s adulthood, therefore Depression and obesity have adolescence, understanding the potentially influencing opporshared similar symptoms, overlap of the variables, and how tunities for developing satisfysuch as complaints of poor to address them in practice, is ing relationships.14 Overweight self-image, depressed mood, critical for the primary care youth initially free of psyprovider. chopathology, particularly sleep difficulties, sedentary The purposes of this paper females, are more likely to behavior, and unregulated therefore are to discuss the endure significant depression food intake. and anxiety later in interface and common pathways adulthood.17 of obesity and depression in the Thoughts, mood, and adolescent population and behavior have been linked conceptually in the cognitive examine strategies that PCPs can incorporate into behavioral model of depression. Interventions typically practice regarding the management of obesity and targeting one of these components are expected to infludepression in this target population. ence the other two.18 For adolescents who are obese, these cognitive processes regarding their self-image are DEPRESSION AND OBESITY: THE OVERLAP often negative.The thoughts can then become internalFor the most part, obesity and depression have been ized, and can affect motivation to address concerns relatcompartmentalized as separate health problems of a 7 ed to increased weight.16,19 Multiple studies19 also have physical and emotional nature, respectively. However, depression and obesity have shared similar symptoms linked childhood obesity to depressed mood. Depressed such as complaints of poor self-image, depressed mood, mood in childhood and adolescence was associated with sleep difficulties, sedentary behavior, and dysregulated a 1.90- to 3.50-fold increased risk of BMI greater than food intake.4 These symptoms are diagnostic criteria for the 95% percentile for age and gender later in life.5 Low depression and may serve as links between obesity and self-image has also been associated with adolescent overdepression. weight and overeating, even after controlling for body mass index.20 Self-Image Non-physical consequences of adolescent obesity such Depressed Mood as: being depressed, socially isolated, or discriminated Depression indicators include depressed mood, anhedoagainst; having poor self-esteem and body image distornia (diminished interest or pleasure from normally pleastions; and being less preferred as friends and more likely urable events/activities), fatigue, feelings of guilt or to be the targets of teasing or bullying are less frequentworthlessness, thoughts of death, as well as changes in ly considered in the literature.8-13 Despite the increase in sleep, appetite, or psychomotor activity. Problems with prevalence of overweight and obesity, stigma, prejudice, sleep, appetite, and psychomotor activity can occur in 256

The Journal for Nurse Practitioners - JNP

April 2009

either direction — individuals may experience insomnia Sedentary Behavior or hypersomnia, anorexia or increased appetite, psyA central feature of depression is lack of interest and chomotor retardation or agitation.The Diagnostic and decreased physical activity with an increase in sedentary Statistical Manual IV text revised (DSM-IV-TR)20 critebehavior.Thought processes affect mood and can signifiria for a major depressive disorder (MDD) episode stipucantly influence adolescents’ psychosocial engagement, late that 5 of 9 possible depression criteria must be presphysical activity, and lifestyle choices (eg, obese youth are ent for most of the time over a 5 times more likely to avoid 2-week period; one of the criteparticipating in sports and ria must include either depressed other school activities and have Although sleep deprivation mood or diminished interest or lower emotional, social, and pleasure, and the symptoms must school functioning).24 has not been irrefutably be a change from prior functionImplications of sedentary demonstrated as an ing.20 There are 2 differences in behavior, depression, and obesiindependent risk factor how depression is diagnosed in ty are multidirectional. As such, for depression and obesity, youth compared with adults. increased interaction with Mood may be irritable, instead peers may improve mood as it is an intervention that the of depressed or anhedonic, and well as thoughts of self-esteem PCP can address. youth may meet symptom crite(“other classmates like to play ria if they fail to make expected with me”). Many sedentary gains in growth rather than activities are considered pleasexperience weight loss from decreased appetite. Subtypes urable by youth (eg, playing a favorite video game).25 of MDD often related to youth include atypical, melanHowever, exclusive pursuit of sedentary activities procholic, catatonic, or chronic depression features.20 motes social isolation as well as decreased physical activity. Increased sedentary behavior is also likely to sustain or Sleep worsen obesity unless there is significant reduction in Sleep problems are a known feature in adolescent food intake.25 Therefore, reduction in sedentary behavior depression and may be difficult to treat.21 Sleep changes may help improve obesity by increased energy expendiin the depressed adolescent can present differently with ture and improve mood by increased social each individual (eg, sleep change can be insomnia or interaction/support. hypersomnia). Symptoms of insomnia may serve as links between adolescent depression and obesity, and a possible Appetite and Food Intake target for intervention for both disorders. Adolescents Another symptom associated with both depression and with depression have prolonged sleep latency compared obesity is change in appetite. Obesity arises out of an with nondepressed adolescents.21 In a cross-section imbalance between energy intake and expenditure. 22 study of 383 adolescents ages 11 to 16 years, wrist Appetite changes, or desire to eat, can go either direction actigraphy was used to objectively measure sleep. Obese in the depressed adolescent (anorexia or hyperphagia). adolescents experienced less total sleep time than nonFor the context of this paper, the focus will be hyper22 obese youths. While decrease in sleep is not a consistent phagia. In a community sample of adolescents diagnosed feature in depression or obesity, sleep deprivation may with MDD, both hyperphagia and depressed mood were contribute to a worsening of both depression and obesiassociated with recurrence of depression in adulthood.26 22 ty. As sleep deprivation, or insomnia, is associated with In adolescents diagnosed with seasonal depression, increased hunger and decreased insulin sensitivity, obesity increased carbohydrate and subsequent weight gain was 23 can likely be exacerbated. Additionally, sleep deprivareported during depressive episodes.27 One hypothesis tion may also affect mood, and is associated with regarding the role in the association between depressive increased suicidality in depressed patients.4 Although symptoms is that increases in food intake and overweight sleep deprivation has not been irrefutably demonstrated are due to disturbances in central serotonergic pathyas an independent risk factor for sleep and obesity, it is ways.4 Studies also suggest that depressive symptoms and an intervention that the PCP can address. weight gain could be related to dysregulation.27 Ethnic www.npjournal.org

The Journal for Nurse Practitioners - JNP

257

and racial differences have been identified regarding their relationship with self-esteem and eating behavior. For Caucasian and Hispanic girls, low self-esteem has been associated with being overweight to a greater degree than among African American girls.28 Thus, there is evidence that unhealthy eating behavior is associated with low selfesteem and that this may vary among ethnic and racial groups. Given the bi-directional effects of depression and obesity, primary health care providers need to be more alert regarding the presentation of depression among youth among diverse ethnic groups of adolescents.

toms, higher mental health-related quality of life, and greater satisifcation with their mental health care than those referred for the usual standard of care.30 For the PCP, it is important therefore to focus more attention on the emotional effect of obesity and the mental health of the adolescent.This involves a comprehensive review with the obese adolesent of patterns of sleep, activity, and appetite, as well as assessment of mood and self-image. If any cues are present that suggest depressive symptoms, screening tools for depression, although they require more time, may be indicated. Few pediatric providers consistently check for signs of anxiety, depresCLINICAL IMPLICATIONS sion, or related signs of distress, even though screening Primary preventive measures (eg, universal depression tools can be used as part of the assessment process.31 screening) should take place with all adolescents and Although the scores derived by such instruments do not their families. Moreover, depression screening (eg, in provide definitive diagnostic information, they can be schools, primary health care) can facilitate early identifi- used as a basis for making appropriate referrals for further cation and timely referral to assessment and possible interprevention and treatment provention.Table 1 details specific grams. Screening overweight screening tools validated for use in the primary care setting. and obese adolescents for menScreening overweight and Adherence to current clinital health concerns and providcal practice guidelines32,33 to ing treatment is essential to obese adolescents for mental prevent or treat childhood enabling effective lifestyle health concerns and providoverweight or obesity is an change to occur. Many families ing treatment is essential to important component to assisthave limited access to specialty enabling effective lifestyle ing the patient in weight manmental health care or prefer to agement, and hopefully receive their mental health care change to occur. improving mood, if there are for their adolescent in the pri29 sympotms of mood disorder. mary care setting. This underscores the importance that Because excessive weight gain, PCPs need to understand how to approach, manage, and social stigmatization, and lower self-esteem can lead to effectively treat depressive symptoms in the primary care depressive symptoms, children with weight problems may setting. The following are strategies suggested for inneed to be viewed as a high-risk group for depression. office approaches to management of obesity and depres- The American Academy of Pediatrics Committee on sion, and the relevance of referring youth and families Obesity Prevention34 recommends that PCPs routinely to mental health specialists for care (eg, advanced pracmonitor children’s BMI and provide guidance to parents tice mental health nurses, licensed clinical social workregarding healthy eating habits, physical activity, and ers, psychologists, and psychiatrists). emerging symptoms of depression.34 One example of a comprehensive, holistic approach to obesity management Primary Care Approach is the The Healthy Eating and Activity Together (HEAT) One study30 conducted from 1999 to 2003 aimed to guideline developed by the National Association of increase access of adolescents with depression to eviPediatric Nurse Practitioners. It provides culturally approdenced-based treatments by primary care PCPs trained in priate screening tools that include an outline for the PCP cognitive behavioral therapy.When mental health issues of to screen for not only depression but other comorbidities adolescents were treated in the primary care setting by as well.33 trained PCPs, at 6 months, those patients receiving the Cognitive monitoring is a useful strategy to identify intervention reported significantly fewer depressive symp- irrational beliefs about eating, cognitive distortions, and 258

The Journal for Nurse Practitioners - JNP

April 2009

Table 1. Depression Screening Instruments Age Range/Years

No. of Items

Clinical Cut-Off

13-18

21

20-28 (moderate depression)

Beck Depression Inventory–2nd ed (BDI-II)49

29 + (severe depression) t scores ⱖ 65 clinically significant

Children’s Depression Inventory (CDI)

17-19

27

Moods and Feelings Questionnaire (MFQ)

8-17

32 (long) 11 (brief)

ⱖ 12 for adolescents ⱖ 9 for children

Kutcher Adolescent Depression Scale

12-18

16 (long) 6 (brief)

6 indicator for depression

Reynolds Adolescent Depression Scale

13-18

30

77 indicates a clinically significant level of depression

Columbia Depression Scale (CDS)

11-18

22

16+ (high likelihood for depression)

Center for Epidemiological Studies Depression Scale for Adolescents

2-18

20

19 or higher indicating depressed mood

50

(CES-D)40

Table 2. Pharmacotherapy for Adolescent Treatment of Depression*§ Drug Dose (mg/d) Citalopram (Celexa)

Increments (mg)

Effective Dose (mg)

Maximum Dose (mg)

10

10

20

*Fluoxetine (Prozac)

10

10-20

20

Fluvoxamine (Luvox)

50

50

150

Paroxetine (Paxil)

10

10

20

Sertraline (Zoloft)

25

12.5-25

50

Escitalopram (Lexapro)

5

5

10

*Children and adolescents taking antidepressants should be monitored closely for suicidal thoughts and behavior. There is a cautionary label or “blackbox warning” used to treat depression for this population. §The FDA has only approved Prozac (fluoxetine). All licensed health providers with prescriptive authority have the option of prescribing medications for “off-label” use based on their clinical judgment of an individual’s treatment needs. Off-label use, which consists of using a medication for medical conditions that are not recognized on the FDA approved labeling for that medication, is a common practice.

the association between thoughts, feelings, and behaviors associated with diet and exercise.35 Cognitive restructuring can then correct or mitigate distorted thinking around food and weight that adolescents may have such as “I will never be able to lose weight,” “My obesity runs in the family. I can’t do anything about it,” “If the food is fat-free (or low fat), the calories do not count,” or “I should always finish my plate.” Properly identifying “permission statements” and other irrational beliefs may help reframe these cognitions to be more conducive to weight loss.36 Youth with cognitive distortions are therefore at increased risk of poorer adherence to treatment recommendations for both obesity and depression. Recognition can also be increased when PCPs more frequently ask parents, or adolescents themselves, about www.npjournal.org

stress or personal emotional difficulties.The process can be enhanced by having a welcoming environment, and taking time to listen carefully, and build rapport. Obese adolescents, as per guidelines for prevention and treatment of obesity in children,37 require additional support and follow-up from PCPs to monitor weight and comorbidities, if present. If screening for depression determines that an adolescent is depressed, a referral process to a specialist or other mental health services should be instituted. Referral Process The mental health specialist tends to initiate and manage psychopharmacologic agents (Table 2), side effects of psychopharmacologic agents (Table 3), and psychotherapy strategies (Table 4). Because of the fragmenThe Journal for Nurse Practitioners - JNP

259

Table 3. Common Adverse Effects of SSRIs With SSRI use

If SSRI is decreased or discontinued

Akathisia or motor restlessness

Dizziness

Dizziness

Headache

Headache

Impaired concentration

Treatment-emergent agitation or hostility

Lightheadedness

Tremor

Nausea

Drowsiness

Drowsiness

Gastrointestinal symptoms

Fatigue

tation of the mental health system, a gap can potentially exist in communication between the mental health provider and PCP providers, leading to a gap in the feedback loop necessary for continuity in care.38 To prevent this, it is important to communicate the potential benefits of receiving mental health services with the adolescent and family, and explain the likely duration of therapy and, in the components of the initial mental health consultation, discuss any costs that can be incurred. Working closely with the mental health specialist, while providing weight managment strategies for the adolescent, will only increase his or her chances for success. The goal of communication with the adolescent and family is to obtain their active participation and ownership of a plan that meets the adolescent’s needs and is most likely to result in optimal mental and physical health.39 Communication should occur in a manner that is developmentally and linguistically appropriate for the patients and their families. Cultural factors need to also be considered, as they can affect diagnosis and management of depression. Finally, the patient and family should be made aware of the limits of confidentiality, including the need to involve parents if there is an imminent risk of harm to the patient or others. It is a requisite that PCPs are familiar with their state laws regarding confidentiality. CONCLUSION Overall, to address the complex, multifactorial healthrelated concerns of obesity and depression among youth, a more proactive approach in prevention and early intervention is required. Collaborating across professional 260

The Journal for Nurse Practitioners - JNP

Table 4. Counseling/Therapy Strategies for Treatment of Depression Type

Philosophical Underpinning

Cognitive-behavior therapy (CBT)41-43

Depressed individuals have cognitive distortions of themselves, the world, and the future.44 CBT assists in identifying negative or dysfunctional interpretations of events and substituting these with positive thought patterns. This technique shows promise for use in primary care in the prevention of depression in children and adolescents.45

Interpersonal psychotherapy (IPT)42,46

Focuses on working through disturbed personal relationships that may contribute to depression. The focus of IPT is on improving current functioning and interpersonal relationships. IPT-A, adapted for adolescents, addresses 5 interpersonal problem areas: interpersonal role disputes, role transition, interpersonal deficits, grief, and single-parent families. The IPT-A intervention can be learned and delivered by social workers, psychologists, and nurses who work in health clinics.46

Family therapy41,42

Family therapy focuses on altering family interactions. Therapists focus on improving the presenting problem and relationship patterns associated with the identified problem.47 Family therapy appears to be more effective for younger children with depression.48

groups and heightening sensitivity to both physiological and psychological factors may serve to improve health outcomes for youth in the United States who are suffering from traditional “adult onset” health problems. April 2009

References 1. National Center for Health Statistics. NCHS and CDC 2000 growth charts: United States. Center for Disease Control; 2008. 2. Wang Y, Beydoun M. The obesity epidemic in the United States: gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and metaregression analysis. Epidemiol Rev. 2007;29:628. 3. Cali AMG, Caprio S. Obesity in children and adolescents. J Clin Endocrinol Metab. 2008;93(11 Supplement 1):s31-36. 4. Reeves G, Postolache T, Snitker S. Childhood obesity and depression: connection between these growing problems in growing children. Int J Child Health Hum Dev. 2008;1:103-114. 5. Liem E, Sauer P, Oldehinkel A, Stolk R. Association between depressive symptoms in childhood and adolescence and overweight later in life. Arch Pediatr Adolesc Med. 2008;162:981-988. 6. Friedman MA, Brownell K. Psychological correlates of obesity: moving to the next research generation. Psych Bull. 1995;117:3-20. 7. Faith M, Matz P, Jorge M. Obesity-depression associations in the population. J Psychosom Res. 2002;53:935-942. 8. Dietz W. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518-524. 9. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5:4-85. 10. Gibson LY, Byrne SM, Blair E, et al. Clustering of psychosocial symptoms in overweight children. Austral N Zealand J Psychiatry. 2008;42:118-125. 11. Petry NM, Barry D, Pietrzak RH, Wagner JA. Overweight and obesity are associated with psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychosomat Med. 2008;70:288-297. 12. Zametkin AJ, Zoon C, Klein H, Munson S. Psychiatric aspects of child and adolescent obesity: a review of the past 10 years. J Am Acad Child Adolesc Psych. 2004;42:134-150. 13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders IV - text revision. 4th ed. Washington DC: American Psychiatric Association; 2000. 14. Puhl R, Brownell K. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obes Rev. 2006;14:1802-1815. 15. Klaczynski PA. There’s something about obesity: culture, contagion, rationality and children’s responses to drinks “created” by obese children. J Exp Child Psychol. 2008;99:58-74. 16. Park J, Schaller M, Crandall C. Pathogen-avoidance mechanisms and the stigmatization of obese people. Evol Human Behav. 2007;28:410-414. 17. Penny H, Haddock G. Anti-fat prejudice among children: the ‘mere proximity’ effect in 5-10 year olds. J Exp Soc Psychol. 2007;43:678-683. 18. Anderson SE, Cohen P, Naumova EN, Jacques PF, Must A. Adolescent obesity and risk for subsequent major depressive disorder and anxiety disorder: prospective evidence. Psychosom Med. 2007;69:740-747. 19. American Academy of Pediatrics and Committee on Prevention. Policy statement: prevention of pediatric overweight and obesity. Pediatrics. 2003;112:424-430. 20. Pine D, Goldstein P, Wolk S, Weissman M. The association between childhood depression and adulthood body mass index. Pediatrics. 2001;107:1049-1056. 21. Ackard DM, Neumark-Sztainer D, Story M, Perry C. Overeating among adolescents: prevalence and associations with weight-related characteristics and psychological health. Pediatrics. 2003;111:67-74. 22. Dahl R, Ryan N, Matty M, et al. Sleep onset abnormalities in depressed adolescents. Biol Psychiatry. 1996;39:400-410. 23. Gupta N, Mueller W, Chan W, Meininger J. Is obesity associated with poor sleep quality in adolescents? Am J Hum Biol. 2002;14:762-768. 24. Spiegel K, Tasali E, Penev P, VanCauter E. Brief communications: sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med. 2004;141:846-850. 25. Schwimmer J, Burwinkle T, Varni J. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1851-1853. 26. Sallis J, Prochaska J, Taylor W. A review of correlates of physical activity in children and adolescents. Med Sci Sports Exerc. 2000;32:963-975. 27. Pettit J, Lewinsohn P, Joiner T Jr. Propagation of major depressive disorder: relationship between first episode symptoms and recurrence. Psychiatry Res. 2006;141:271-278. 28. Arbisi P, Levine A, Nerenberg J, Wolf J. Seasonal alteration in taste detection and recognition threshold in seasonal affective disorder: the proximate source of carbohydrate craving. Psychiatry Res. 1996;59:171-182. 29. Brown KM, McMahon RP, Biro FM, et al. Changes in self-esteem in black and white girls between the ages of 9 and 14 years: the NHLBI Growth and Health Study. J Adolesc Health. 1998;23:7-19. 30. Sayal K. Annotation: pathways to care for children with mental health disorders. J Child Psychol Psychiatry. 2006;47:249-259.

www.npjournal.org

31. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to Venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299(8):901-913. 32. Gardner G, Murphy M, Child G, et al. The PSC-17: a brief pediatric symptom checklist with psychosocial problems subscales: a report from the PROS and ASPN. Ambul Child Health. 1999;5:225-236. 33. Barlow SE, Dietz WH. Management of child and adolescent obesity: summary and recommendations based on reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics. 2002;110(1):236-238. 34. National Association of Pediatric Nurse Practitioners. HEAT: Health Eating and Activity Together: guidelines for the prevention and treatment of obesity. Washington DC: NAPNAP; 2004. 35. Wadden TA, ed. The treatment of obesity. 2nd ed. New York: Raven Press; 1993. 36. Cooper A, Fairburn CG, eds. Cognitive-behavioral treatment of obesity. New York: Guilford Press; 2002. 37. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics. 1998;102(3):E29. 38. Lamberg L. Empirically supported treatments improve care of adolescents with depression. JAMA. 2008;300:269-270. 39. Hampl S, Carroll C, Simon S, et al. Resource utilization and expenditures for overweight and obese children. Arch Pediatr Adolesc Med. 2007;161:1114. 40. Faulstich M, Carey M, Ruggiero L, Enyart P, Gresham F. Assessment of depression in childhood and adolescence: an evaluation of the Center for Epidemiological Studies Depression Scale for Children (CES-DC). Am J Psychiatry. 1986;143:1024-1027. 41. Kennard B, Emslie G, Mayes T, et al. Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. J Am Acad Child Adolesc Psychol. 2008;47:1391-1404. 42. Rossello J, Bernal G. Treatment of depression in Puerto Rican adolescents. J Consult Clin Psychol. 1999;67:734-745. 43. Wood A, Harrington R, Moore A. Controlled trial of a brief cognitivebehavioural intervention in adolescent patients with depressive disorders. J Child Psychol Psychiatry. 1996;37:737-746. 44. Beck AT. Cognitive therapy of depression. New York: Guilford Press; 1979. 45. Asarnow JR, Jaycox LH, Thompson MC. Depression in youth: psychosocial interventions. J Clin Child Psychol. 2001;30:33-47. 46. Mufson L, Dorta K, Wickramaratne P, et al. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 2004;61:577-584. 47. Axelson DA, Birmaher B. Relation between anxiety and depressive disorders in childhood and adolescence. Depress Anxiety. 2001;14:67-78. 48. Stein REK, Zitner LE, Jensen PS. Interventions for adolescent depression in primary care. Pediatrics. 2006;118(2):669-682. 49. Beck AT, Steer RA, Brown GK. Manual for Beck depression inventory-II. San Antonio, TX: Psychcological Corporation, 1996. 50. Kovacs M. The children’s depression inventory (CDI). Psychopharmacol Bull. 1985;21:995-998.

Christina J. Calamaro, PhD, CRNP, and Roberta Waite, EdD, APRN, CNS-BC, are assistant professors in the College of Health and Nursing Sciences at Drexel University in Philadelphia, PA. Calamaro can be reached at [email protected]. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/09/$ see front matter © 2009 American College of Nurse Practitioners doi:10.1016/j.nurpra.2009.01.004

The Journal for Nurse Practitioners - JNP

261