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In his lab at McLean Hospital, Randy P. Auerbach, PhD, ABPP, is using wide-ranging technological advances to improve our understanding of why certain depressed youth develop depression and engage in suicidal behaviors.
“Identifying markers [objectively observable signs of disease] that improve early diagnosis of depression in youth will have profound consequences across a patient’s life span,” said Auerbach, director of Clinical Research for the Nancy and Richard Simches Division of Child and Adolescent Psychiatry and director of the Child and Adolescent Mood Disorders Laboratory. “Our ultimate goal, of course, is to use our findings to advance both prevention and intervention efforts, thereby reducing adolescent distress and needless loss of life.”
Auerbach’s research is multidisciplinary, using a variety of approaches, including lab-based experiments, electrophysiology, functional magnetic resonance imaging, and magnetic resonance spectroscopy, to determine why depressive symptoms unfold, how self-injurious and suicidal behaviors develop, and what changes in the brain during treatment.
Recently, in a series of published papers, Auerbach sought to describe neural processes that may underlie depressotypic self-referential processing biases—the tendency of depressed youth to focus on negative stimuli in their environment—which may prolong and increase the severity of depressive symptoms. Using a systematic approach, Auerbach identified electrophysiological (electric activity in the brain) markers—with millisecond precision—that differentiate depressed and healthy adolescents.1-2 Moreover, Auerbach and colleagues also demonstrated that these effects were present in at-risk, never-depressed adolescents (owing to a maternal history of depression), showing that the neural deficits may be present prior to depression onset.3
“EEG and event-related potentials allow us to probe cognitive-affective processes critically implicated in depression onset,” said Auerbach. “Identifying objective signs of risk may help us develop new preventative-intervention approaches for adolescents.”
Building on this work, Auerbach also is testing whether these markers associated with depressotypic self-referential processing biases also predict treatment response to cognitive behavioral therapy. These findings, which are expected to be published in the next year, may ultimately help direct youth into optimal treatment.
Presently, suicide is the second leading cause of death for adolescents, and while depression is strongly associated with contemplating suicide (ideation), it shows a weaker relationship with attempting suicide. Auerbach’s work, therefore, has sought to identify mechanisms that are directly related to suicide attempts among depressed adolescents.4-5
“About one-third of adolescents who have suicidal thoughts will make a suicide attempt,” said Auerbach. “At the same time, from a clinical perspective, these two groups—ideators and attempters—are extraordinarily difficult to differentiate. Identifying objective means of determining which suicide ideators are most likely to make a suicide attempt would improve our treatment and improve the safety of high-risk adolescents.”
In a recently published article, Auerbach demonstrated that depressed suicide attempters show elevated levels of anhedonia (an inability to experience pleasure) relative to depressed suicide ideators, despite comparable levels of depression, anxiety, and suicidal ideation. Interestingly, anhedonia severity seemed to negatively affect the integration of rewarding experiences into future decision-making. Whereas depressed suicide ideators used reward in prior trials to guide decision-making for future trials, the more anhedonic suicide attempters failed to do so.
“Rewarding experiences guide our decision-making processes and help us all navigate the world around us. For suicide attempters, the failure to experience pleasure and integrate rewarding experiences may contribute to feeling hopeless and helpless. Over time, this may potentially increase risk for suicidal behaviors,” noted Auerbach.
As co-director for the WHO World Mental Health Surveys Initiative International College Student Project, Auerbach has taken a lead role in improving assessment and treatment for depressed college students. In a recently published study in Psychological Medicine that compared college students and same-aged non-students across 21 countries, Auerbach showed that mental illness—particularly depression and substance use disorders—led to increased school dropout rates. Results also indicated that a minority of these affected students received sufficient mental health care.
“Only about one-sixth of college students who reported emotional problems in the past 12 months reported receiving appropriate care,” Auerbach noted. “And, perhaps not surprisingly, rates of use decrease as income decreases. Thus, there is a glaring need for us to find other means to improve access to care.”
In a recently funded National Institute of Mental Health study, Auerbach is working with Dr. Stephanie Pinder-Amaker (McLean Hospital), Dr. Ronald Kessler (Harvard Medical School), and Dr. Pim Cuijpers (University of Amsterdam) to develop a system for rapid online depression assessment. Once identified, students are offered access to internet-based cognitive behavioral therapy for depression. The study was launched in several colleges and universities around the Greater Boston area in fall 2016.
“Our long-term goal will be to develop an algorithm that predicts which individuals are likely to respond to this low-cost, easily disseminable treatment,” said Auerbach. “Once identified, we can then work with colleges and universities to channel students into the optimal level of care.”
Depression has a pernicious impact across the developmental life span, and Dr. Auerbach’s research has taken a systematic approach to improving our understanding of neurocognitive mechanisms implicated in the onset and treatment of major depressive disorder. Although many unanswered questions remain, Dr. Auerbach is steadfast and resolute in his commitment to improve the psychological well-being of all youth.