- Email: [email protected]
Depression in adolescents
PH C
CLINICAL REPORT
GROWTH AND DEVELOPMENT
SECTION EDITOR Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N D e a n , U n ive r s i t y o f Tex a s a t E l Pa s o College of Health Sciences C h a r l e s a n d S h i r l ey L e ave l l E n d owe d C h a i r
Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N
T
he term “depression” has been used to refer to either a simple mood state, a syndrome of associated symptoms, or a clinical disorder. We experience a number of moods in our lives that are transitory and related to specific instances. Moods are unidimensional and can be assessed with a check list. Asyndrome of associated symptoms might include, for example, loss of appetite and insomnia. To be termed a disorder, the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), must be met. The DSM-IV criteria for a major depressive disorder were provided in an article on depression in children in the March/April 2000 issue of this Journal (Castiglia, 2000). The DSM-IV defines depression as a dysphoric mood or loss of interest or pleasure in a person’s usual activities. Depression is characterized by persistent symptoms such as hopelessness, irritability, or feeling blue or sad (American Psychiatric Association, 1994). It appears that, in adolescents, a relationship exists between depression as a mood, a syndrome, and a disorder. Depressed mood is a necessary but not a sufficient criterion for a depressive syndrome which, in turn, is necessary but insufficient alone for the diagnosis of a depressive disorder (Carmanico et al., 1998). Until recent years, depression was not considered a major problem in adolescents. The growing awareness of depression in children younger than 18 years is reflected in the 80% increase of antidepressant prescriptions for children—serotonin re-uptake inhibitors (SSRIs)—from 1994 to 1996 (Byalick, 1998).
180
Depression in Adolescents
If mood swings persist longer than a few days and are severe or interfere with daily activities, adolescents should be referred to a physician, and if the symptoms persist for more than 2 weeks, an evaluation should be conducted. To make a diagnosis of a major depressive episode, 5 or more of the DSM-IV criteria must be present in the same 2-week period.
D
iagnosing depression
in adolescents is challenging because adolescents typically experience developmental changes that may make the diagnosis more difficult.
A dysthymic disorder is less severe than a major depressive episode but lasts longer. A dysthymic disorder is defined as a depressed or excitable mood lasting at least 1 year. It may sub-
side from time to time, but the person is not free of symptoms for more than 2 months in the year (Brown-Jones & Orr, 1996). Diagnosing depression in adolescents is challenging because adolescents typically experience developmental changes that may make the diagnosis more difficult. Adolescents may also exhibit anxiety disorder or substance abuse, and these problems must be recognized and appropriately treated. Genetics has not been identified as a predisposing factor for depression. However, it has been estimated that parents and siblings as well as children of severely depressed people have a morbidity risk of about 20% for mood disorders (Nurnberger & Gershon, 1992). Erikson’s developmental theory is often used as a reference for adolescent depression. Each stage has a resolution with positive or negative effects. The development of self-identity is related to the resolution of previous steps. Many other theoretical formulations, including psychoanalytical theory and family theory, may be used as a framework. Despite the theoretical foundation used, adolescents tend to present with some or all of the following symptoms: loneliness, low self-esteem, sadness, eating disorders, acting-out behaviors and discipline problems, and stressful life events (Brage, 1995). One theory of depression focuses on monoamine neurotransmission. It has
J Pediatr Health Care. (2000). 14, 180-182. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/8/107817 doi:10.1067/mph.2000.107817
July/August 2000
PH GROWTH AND DEVELOPMENT C been proposed that an alteration may occur in the receptors as well as in the concentration or turnover of the amines. This theory receives some support in the literature because monoamine neurotransmitters, that is, indolamine, serotonin, and the catecholamines (norepinephrine and dopamine) have been implicated in mood disorders. Functional decreases in serotonin, for example, are found in persons with depression, whereas very high levels are implicated in mania (Mohr, 1998). Circadian rhythm disturbances have also been considered, because circadian rhythms are less stable during episodes of depression. Levels of melatonin, a hormone secreted during sleep, have been found to be reduced during episodes of depression (Brage, 1995). Another theory, the learned helplessness theory, suggests that depressed adolescents have experienced feelings of helplessness and powerlessness and that their inability to master their environment results in feelings of passivity, hopelessness, and an inability to assert themselves. These adolescents may set high goals for themselves, but they expect to fail and then tend to punish themselves for failure while not rewarding themselves for success. Low self-esteem and depression may result (Kovacs & Beck, 1978). It has been consistently reported that by age 18 years, girls have twice the rate of depression as boys. The rate of depression for girls rises sharply between the ages of 11 and 15 years. Girls tend to identify symptoms similar to those reported by adults, whereas boys report feelings of contempt and self-loathing. Boys tend to engage in behaviors such as substance abuse, theft, and running away, that is, acting-out behaviors. Berman and Schwartz (1990) noted that depression is greater among drug abusers than among nonabusers and among abusive consumers of alcoholic beverages compared with nonabusive drinkers. A positive relationship has been identified between drug use and suicide attempts. In addition, gay and lesbian adolescents are two to three times more likely to commit suicide than are other adolescents (Allen & Glicken, 1996). Nursing assessments include 3 areas: history taking and observation, questionnaires, and biological tests (Brage, 1995). Histories must be taken from the
JOURNAL OF PEDIATRIC HEALTH CARE
Castiglia
parents as well as from the adolescent. Recent changes in behavior in such areas as peer situations, family situations, and school performance and school attendance, as well as signs or evidence of substance abuse, should be elicited. Other important questions include the following: Have there been other changes such as persistent fatigue, sleep disturbances, changes in eating behaviors, an increase in accidents, or sexual promiscuity? What is the adolescent’s affect? What behavior is observed? Questionnaires frequently used in assessment include the Beck Depressive Inventory (Beck, 1967), which focuses on cognitive items, the Center of Epidemiologic Studies Depression Scale of Children (CES-DC) (Radloff & Locke, 1986), the Hamilton Rating Scale, which focuses on biological elements (Hamilton, 1960), and the Schedule for Affective Disorders and Schizophrenia for School-Age Children and Adolescents (K-SADS), which is useful in identifying adolescents with bipolar disorder (Gamma & Rothbaum, 1983). A bipolar diagnosis includes both mania and depression, as described in the article on depression in children in the March/April 2000 issue of this Journal (Castiglia, 2000).
T
he rate of depression
for girls rises sharply between the ages of 11 and 15 years.
Other assessment measures include the Children’s Depression Inventory (Kovacs, 1983), the Mood and Feelings Questionnaire (Angold, Costello, Pickles, & Winder, 1987), and the Diagnostic Interview Schedule for Children—Child Report: Depressive Modules (Shaffer et al., 1993). Biological tests that may be useful include the dexamethasone suppression test, a blunted thyroid-stimulating hormone response to thyroid-releasing hormone, and the sleep electroencephalogram response. The dexamethasone suppression test is the most frequently
used test; it is accurate for depression in 25% to 60% of patients. If depression is present, when the adolescent is given dexamethasone, cortisol levels are not suppressed (Brown-Jones & Orr, 1996). Therapies that may be used include cognitive-behavioral therapy, family therapy, and drug therapy. Through one-to-one contact and group therapy, adolescents can learn to focus on their strengths and interests rather than on their perceived negative qualities. Parents can learn how to offer positive feedback. In cognitive therapy, the goals are to improve the adolescent’s interpersonal skills and alter negative self-perceptions (Brage, 1995). Working with the families of adolescents exhibiting depression is essential. Parents must be assisted in developing better parenting and nurturing skills and in identifying how they can help their child overcome feelings of low self-esteem and helplessness. This task must be done in a manner that reduces parental guilt and secures parental cooperation. Often parents must be taught new coping mechanisms. The use of psychotropic medications remains controversial. It appears that use of antidepressants is appropriate for cases of severe depression. Tricyclic antidepressants (TCAs) are considered relatively safe for the treatment of depression in adolescents. Two examples of TCAs are desipramine and imipramine. TCAs act to increase the levels of norepinephrine, serotonin, and dopamine at the synapse (Mohr, 1998). Pharmacologic monitoring is essential because hepatic metabolism is more rapid and more efficient in young people. They have an increased glomerular filtration rate and hormone activity, which also may interfere with TCA metabolism. Prescribing multiple rather than daily dosages is recommended (Mohr, 1998). Other medications that may be used to alleviate depression include SSRIs. An example is fluoxetine (Prozac). Sometimes TCAs and SSRIs are combined with lithium in patients who do not respond to other medications well. Monoamine oxidase inhibitors have been found to be safe and effective for treating depression in adolescents (Mohr, 1998). The use of any medication for depression in adolescents must be approached with caution and should be prescribed only by those well qualified to do so. Treatment is not accomplished by medication alone. Psychotherapy is usually
July/August 2000
181
PH GROWTH AND DEVELOPMENT C initiated after the adolescent begins to respond to drug therapy. Mood disturbances, either unipolar (depressive) or bipolar (manic-depressive), are the most common mental health problem encountered. Management has become increasingly important as mental health continues to be included under managed care. In primary care settings, the practitioner (nurse, physician, or physician assistant) must be alert for signs and symptoms of depression. Early identification and intervention are more likely to have a greater success, to be less costly to the adolescent and parents, and to foster greater happiness and a sense of fulfillment for all persons involved.
REFERENCES Allen, L. B., & Glicken, A. D. (1996). Depression and suicide in gay and lesbian adolescents. Physician Assistant, 20, 44, 46, 52-4. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Angold, A., Costello, E. J., Pickles, A., & Winder, F. (1987). The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Lender: Medical Re-
Castiglia
search Council Child Psychiatry Unit. Cited in Cormanico, S. J., Erickson, M. T., Singh, N. N., Best, A. M., Sood, A. A., & Oswald, D. P. (1998). Diagnostic subgroups of depression in adolescents with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders, 4, 223. Beck, A. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & Row. Berman, A. L., & Schwartz, R. H. (1990). Suicide attempts among adolescent drug users. American Journal of Diseases of Childhood, 144, 310-314. Brage, D. G. (1995). Adolescent depression: A review of the literature. Archives of Psychiatric Nursing, 1X, 45-55. Brown-Jones, L. C., & Orr, D. P. (1996). Enlisting parents as allies against depression. Contemporary Pediatrics, 13, 67, 71-72, 74. Byalick, M. (1998, May 3). More pupils taking prescribed drugs to relieve distress. The New York Times, Section 14LI, p. 10. Carmanico, S. J., Erickson, M. T., Singh, N. N., Best, A. N., Sood, A. A., & Oswald, D. P. (1998). Diagnostic subgroups of depression in adolescents with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders, 6, 222-232. Castiglia, P. T. (2000). Depression in children. Journal of Pediatric Health Care, 14, 73-75. Gamma, C., & Rothbaum, E. (1983). Use of a structured interview to identify bipolar disorder in adolescent inpatients: Frequency and manifestation of the disorder. American Journal of Psychiatry, 140, 343-347.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurological Neurosurgical Psychiatry, 23, 56-61. Kovacs, M. (1983). The children’s depression inventory. Unpublished manuscript, University of Pittsburgh. Cited in Carmanico, S. J., Erickson, M. N. T., Singh, N. N., Best, A. M., Good, A. A., & Oswald, D. P. (1998). Diagnostic subgroups of depression in adolescents with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders 4, 223. Kovacs, M., & Beck, A. (1978). Maladaptive cognitive structures in depression. American Journal of Psychiatry, 135, 525-533. Mohr, W. K. (1998). Updating what we know about depression in adolescents. Journal of Psychosocial Nursing, 36, 12-19. Numberger, J. A., & Gershon, E. S. (1992). Genetics. In E. S. Paykel (Ed.), Handbook of affective disorders (pp. 132-148). Edinburgh, United Kingdom: Churchill Livingstone. Radloff, L., & Locke, B. (1986). The community mental health assessment survey and the DES-D Scale. In M. Wessman, J. Myers, & C. Ross (Eds.), Community surveys of psychiatric disorders (pp. 177-189). New Brunswick, NJ: Rutgers University Press. Shaffer, D., Schwab-Stone, M., Fischer, C., Cohen, C., Placentine, J., Davies, M., Conners, C. K., & Regier, D. (1993). The diagnostic interview schedules for children. Revised version (DISE-R): Preparation, field testing, interrater reliability and acceptability. Journal of the American Academy for Child and Adolescent Psychiatry, 32, 643-650.
Receive Journal of Pediatric Health Care tables of contents by E-mail To receive Journal of Pediatric Health Care tables of contents by E-mail, sign up through our Web site at http://www.mosby.com/pedhc Choose E-mail Notification. Simply type your E-mail address in the box and click the Subscribe button. Alternatively, you may send an E-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe pedhc_toc You will receive an E-mail to confirm that you have been added to the mailing list. Note that table of contents E-mails will be sent out when a new issue is posted to the Web site.
182
Volume 14 Number 4
JOURNAL OF PEDIATRIC HEALTH CARE
CLINICAL REPORT
GROWTH AND DEVELOPMENT
SECTION EDITOR Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N D e a n , U n ive r s i t y o f Tex a s a t E l Pa s o College of Health Sciences C h a r l e s a n d S h i r l ey L e ave l l E n d owe d C h a i r
Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N
T
he term “depression” has been used to refer to either a simple mood state, a syndrome of associated symptoms, or a clinical disorder. We experience a number of moods in our lives that are transitory and related to specific instances. Moods are unidimensional and can be assessed with a check list. Asyndrome of associated symptoms might include, for example, loss of appetite and insomnia. To be termed a disorder, the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), must be met. The DSM-IV criteria for a major depressive disorder were provided in an article on depression in children in the March/April 2000 issue of this Journal (Castiglia, 2000). The DSM-IV defines depression as a dysphoric mood or loss of interest or pleasure in a person’s usual activities. Depression is characterized by persistent symptoms such as hopelessness, irritability, or feeling blue or sad (American Psychiatric Association, 1994). It appears that, in adolescents, a relationship exists between depression as a mood, a syndrome, and a disorder. Depressed mood is a necessary but not a sufficient criterion for a depressive syndrome which, in turn, is necessary but insufficient alone for the diagnosis of a depressive disorder (Carmanico et al., 1998). Until recent years, depression was not considered a major problem in adolescents. The growing awareness of depression in children younger than 18 years is reflected in the 80% increase of antidepressant prescriptions for children—serotonin re-uptake inhibitors (SSRIs)—from 1994 to 1996 (Byalick, 1998).
180
Depression in Adolescents
If mood swings persist longer than a few days and are severe or interfere with daily activities, adolescents should be referred to a physician, and if the symptoms persist for more than 2 weeks, an evaluation should be conducted. To make a diagnosis of a major depressive episode, 5 or more of the DSM-IV criteria must be present in the same 2-week period.
D
iagnosing depression
in adolescents is challenging because adolescents typically experience developmental changes that may make the diagnosis more difficult.
A dysthymic disorder is less severe than a major depressive episode but lasts longer. A dysthymic disorder is defined as a depressed or excitable mood lasting at least 1 year. It may sub-
side from time to time, but the person is not free of symptoms for more than 2 months in the year (Brown-Jones & Orr, 1996). Diagnosing depression in adolescents is challenging because adolescents typically experience developmental changes that may make the diagnosis more difficult. Adolescents may also exhibit anxiety disorder or substance abuse, and these problems must be recognized and appropriately treated. Genetics has not been identified as a predisposing factor for depression. However, it has been estimated that parents and siblings as well as children of severely depressed people have a morbidity risk of about 20% for mood disorders (Nurnberger & Gershon, 1992). Erikson’s developmental theory is often used as a reference for adolescent depression. Each stage has a resolution with positive or negative effects. The development of self-identity is related to the resolution of previous steps. Many other theoretical formulations, including psychoanalytical theory and family theory, may be used as a framework. Despite the theoretical foundation used, adolescents tend to present with some or all of the following symptoms: loneliness, low self-esteem, sadness, eating disorders, acting-out behaviors and discipline problems, and stressful life events (Brage, 1995). One theory of depression focuses on monoamine neurotransmission. It has
J Pediatr Health Care. (2000). 14, 180-182. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/8/107817 doi:10.1067/mph.2000.107817
July/August 2000
PH GROWTH AND DEVELOPMENT C been proposed that an alteration may occur in the receptors as well as in the concentration or turnover of the amines. This theory receives some support in the literature because monoamine neurotransmitters, that is, indolamine, serotonin, and the catecholamines (norepinephrine and dopamine) have been implicated in mood disorders. Functional decreases in serotonin, for example, are found in persons with depression, whereas very high levels are implicated in mania (Mohr, 1998). Circadian rhythm disturbances have also been considered, because circadian rhythms are less stable during episodes of depression. Levels of melatonin, a hormone secreted during sleep, have been found to be reduced during episodes of depression (Brage, 1995). Another theory, the learned helplessness theory, suggests that depressed adolescents have experienced feelings of helplessness and powerlessness and that their inability to master their environment results in feelings of passivity, hopelessness, and an inability to assert themselves. These adolescents may set high goals for themselves, but they expect to fail and then tend to punish themselves for failure while not rewarding themselves for success. Low self-esteem and depression may result (Kovacs & Beck, 1978). It has been consistently reported that by age 18 years, girls have twice the rate of depression as boys. The rate of depression for girls rises sharply between the ages of 11 and 15 years. Girls tend to identify symptoms similar to those reported by adults, whereas boys report feelings of contempt and self-loathing. Boys tend to engage in behaviors such as substance abuse, theft, and running away, that is, acting-out behaviors. Berman and Schwartz (1990) noted that depression is greater among drug abusers than among nonabusers and among abusive consumers of alcoholic beverages compared with nonabusive drinkers. A positive relationship has been identified between drug use and suicide attempts. In addition, gay and lesbian adolescents are two to three times more likely to commit suicide than are other adolescents (Allen & Glicken, 1996). Nursing assessments include 3 areas: history taking and observation, questionnaires, and biological tests (Brage, 1995). Histories must be taken from the
JOURNAL OF PEDIATRIC HEALTH CARE
Castiglia
parents as well as from the adolescent. Recent changes in behavior in such areas as peer situations, family situations, and school performance and school attendance, as well as signs or evidence of substance abuse, should be elicited. Other important questions include the following: Have there been other changes such as persistent fatigue, sleep disturbances, changes in eating behaviors, an increase in accidents, or sexual promiscuity? What is the adolescent’s affect? What behavior is observed? Questionnaires frequently used in assessment include the Beck Depressive Inventory (Beck, 1967), which focuses on cognitive items, the Center of Epidemiologic Studies Depression Scale of Children (CES-DC) (Radloff & Locke, 1986), the Hamilton Rating Scale, which focuses on biological elements (Hamilton, 1960), and the Schedule for Affective Disorders and Schizophrenia for School-Age Children and Adolescents (K-SADS), which is useful in identifying adolescents with bipolar disorder (Gamma & Rothbaum, 1983). A bipolar diagnosis includes both mania and depression, as described in the article on depression in children in the March/April 2000 issue of this Journal (Castiglia, 2000).
T
he rate of depression
for girls rises sharply between the ages of 11 and 15 years.
Other assessment measures include the Children’s Depression Inventory (Kovacs, 1983), the Mood and Feelings Questionnaire (Angold, Costello, Pickles, & Winder, 1987), and the Diagnostic Interview Schedule for Children—Child Report: Depressive Modules (Shaffer et al., 1993). Biological tests that may be useful include the dexamethasone suppression test, a blunted thyroid-stimulating hormone response to thyroid-releasing hormone, and the sleep electroencephalogram response. The dexamethasone suppression test is the most frequently
used test; it is accurate for depression in 25% to 60% of patients. If depression is present, when the adolescent is given dexamethasone, cortisol levels are not suppressed (Brown-Jones & Orr, 1996). Therapies that may be used include cognitive-behavioral therapy, family therapy, and drug therapy. Through one-to-one contact and group therapy, adolescents can learn to focus on their strengths and interests rather than on their perceived negative qualities. Parents can learn how to offer positive feedback. In cognitive therapy, the goals are to improve the adolescent’s interpersonal skills and alter negative self-perceptions (Brage, 1995). Working with the families of adolescents exhibiting depression is essential. Parents must be assisted in developing better parenting and nurturing skills and in identifying how they can help their child overcome feelings of low self-esteem and helplessness. This task must be done in a manner that reduces parental guilt and secures parental cooperation. Often parents must be taught new coping mechanisms. The use of psychotropic medications remains controversial. It appears that use of antidepressants is appropriate for cases of severe depression. Tricyclic antidepressants (TCAs) are considered relatively safe for the treatment of depression in adolescents. Two examples of TCAs are desipramine and imipramine. TCAs act to increase the levels of norepinephrine, serotonin, and dopamine at the synapse (Mohr, 1998). Pharmacologic monitoring is essential because hepatic metabolism is more rapid and more efficient in young people. They have an increased glomerular filtration rate and hormone activity, which also may interfere with TCA metabolism. Prescribing multiple rather than daily dosages is recommended (Mohr, 1998). Other medications that may be used to alleviate depression include SSRIs. An example is fluoxetine (Prozac). Sometimes TCAs and SSRIs are combined with lithium in patients who do not respond to other medications well. Monoamine oxidase inhibitors have been found to be safe and effective for treating depression in adolescents (Mohr, 1998). The use of any medication for depression in adolescents must be approached with caution and should be prescribed only by those well qualified to do so. Treatment is not accomplished by medication alone. Psychotherapy is usually
July/August 2000
181
PH GROWTH AND DEVELOPMENT C initiated after the adolescent begins to respond to drug therapy. Mood disturbances, either unipolar (depressive) or bipolar (manic-depressive), are the most common mental health problem encountered. Management has become increasingly important as mental health continues to be included under managed care. In primary care settings, the practitioner (nurse, physician, or physician assistant) must be alert for signs and symptoms of depression. Early identification and intervention are more likely to have a greater success, to be less costly to the adolescent and parents, and to foster greater happiness and a sense of fulfillment for all persons involved.
REFERENCES Allen, L. B., & Glicken, A. D. (1996). Depression and suicide in gay and lesbian adolescents. Physician Assistant, 20, 44, 46, 52-4. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Angold, A., Costello, E. J., Pickles, A., & Winder, F. (1987). The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Lender: Medical Re-
Castiglia
search Council Child Psychiatry Unit. Cited in Cormanico, S. J., Erickson, M. T., Singh, N. N., Best, A. M., Sood, A. A., & Oswald, D. P. (1998). Diagnostic subgroups of depression in adolescents with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders, 4, 223. Beck, A. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & Row. Berman, A. L., & Schwartz, R. H. (1990). Suicide attempts among adolescent drug users. American Journal of Diseases of Childhood, 144, 310-314. Brage, D. G. (1995). Adolescent depression: A review of the literature. Archives of Psychiatric Nursing, 1X, 45-55. Brown-Jones, L. C., & Orr, D. P. (1996). Enlisting parents as allies against depression. Contemporary Pediatrics, 13, 67, 71-72, 74. Byalick, M. (1998, May 3). More pupils taking prescribed drugs to relieve distress. The New York Times, Section 14LI, p. 10. Carmanico, S. J., Erickson, M. T., Singh, N. N., Best, A. N., Sood, A. A., & Oswald, D. P. (1998). Diagnostic subgroups of depression in adolescents with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders, 6, 222-232. Castiglia, P. T. (2000). Depression in children. Journal of Pediatric Health Care, 14, 73-75. Gamma, C., & Rothbaum, E. (1983). Use of a structured interview to identify bipolar disorder in adolescent inpatients: Frequency and manifestation of the disorder. American Journal of Psychiatry, 140, 343-347.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurological Neurosurgical Psychiatry, 23, 56-61. Kovacs, M. (1983). The children’s depression inventory. Unpublished manuscript, University of Pittsburgh. Cited in Carmanico, S. J., Erickson, M. N. T., Singh, N. N., Best, A. M., Good, A. A., & Oswald, D. P. (1998). Diagnostic subgroups of depression in adolescents with emotional and behavioral disorders. Journal of Emotional and Behavioral Disorders 4, 223. Kovacs, M., & Beck, A. (1978). Maladaptive cognitive structures in depression. American Journal of Psychiatry, 135, 525-533. Mohr, W. K. (1998). Updating what we know about depression in adolescents. Journal of Psychosocial Nursing, 36, 12-19. Numberger, J. A., & Gershon, E. S. (1992). Genetics. In E. S. Paykel (Ed.), Handbook of affective disorders (pp. 132-148). Edinburgh, United Kingdom: Churchill Livingstone. Radloff, L., & Locke, B. (1986). The community mental health assessment survey and the DES-D Scale. In M. Wessman, J. Myers, & C. Ross (Eds.), Community surveys of psychiatric disorders (pp. 177-189). New Brunswick, NJ: Rutgers University Press. Shaffer, D., Schwab-Stone, M., Fischer, C., Cohen, C., Placentine, J., Davies, M., Conners, C. K., & Regier, D. (1993). The diagnostic interview schedules for children. Revised version (DISE-R): Preparation, field testing, interrater reliability and acceptability. Journal of the American Academy for Child and Adolescent Psychiatry, 32, 643-650.
Receive Journal of Pediatric Health Care tables of contents by E-mail To receive Journal of Pediatric Health Care tables of contents by E-mail, sign up through our Web site at http://www.mosby.com/pedhc Choose E-mail Notification. Simply type your E-mail address in the box and click the Subscribe button. Alternatively, you may send an E-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe pedhc_toc You will receive an E-mail to confirm that you have been added to the mailing list. Note that table of contents E-mails will be sent out when a new issue is posted to the Web site.
182
Volume 14 Number 4
JOURNAL OF PEDIATRIC HEALTH CARE