Examining the brains of depressed teens: A how-to for getting well and staying well
Dr. Rachel Jacobs is tapping into the benefits of translational research to uncover how teenagers who have experienced depression can maintain wellness as they transition into adulthood. Using a combination of functional magnetic resonance imaging (fMRI) and Cognitive Behavioral Therapy (CBT), Jacobs aims to understand how the brains of these adolescents work to keep them happy and healthy.
During Jacobs’ graduate research she questioned why, after treatment, nearly half of teens eventually relapsed back into depression while others stayed well. Now an assistant professor in psychiatry at UIC’s Institute for Juvenile Research, she is seeking an explanation- and a solution.
Depression in adolescence is often predictive of major depressive disorder, which has a high risk for suicide among other behavioral problems. Jacobs states that three or more depressive episodes during the teenage years tend to be predictive of a life-long pattern.
In follow-up interviews with her study participants Jacobs found, “One kid would be in college doing fine, meanwhile another was in rehab with a multitude of problems. So what are the predictors of relapse are there secondary treatments to prevent this?”
Looking beyond her clinical background, Jacobs thought that if researchers could understand cognition at the level of the brain, they could better understand how a cognition-based intervention works. She hypothesized that fMRI- a method commonly used in neuroscience to take pictures of the brain- could serve as a tool to measure cognitive change in those undergoing cognitive treatments for depression.
Based on the assumption that the part of the brain a person is using requires more oxygen, fMRI captures multiple images of a patient’s brain either while giving them a task or when their brain is “at rest.” Jacobs is most interested in examining these resting-state images.
During resting state fMRI, “You are looking at a stationary image and the assumption is that you are not actively engaging in thought. In reality, your brain starts to wander, you plan for the day, or you notice that your arm is falling asleep,” she explains.
A common thought pattern displayed by depressed individuals during resting state is rumination. Coined after cows’ habit of chewing grass all day long, rumination was observed by Jacobs' undergraduate mentor, Dr. Susan Nolen-Hoeksema. Whlie interviewing woman about their mental health, Nolen-Hoeksema observed that women tended to repeatedly think about a problem with the idea that if they thought about it long enough, it would make them feel better. In truth, it made them feel worse.
This process of passively dwelling upon negative thoughts without active problem solving is predictive of depression, alcohol or substance abuse, eating disorders and relapse. It is also more common in women than men.
In Jacobs’ current study each teenage participant has been diagnosed with depression in the past and is currently in remission. Using a multidisciplinary approach, half of the participants receive a rumination-focused CBT intervention- which includes mindfulness and relaxation exercises- while others only undergo assessments that include fMRIs. In addition to looking at the brain “at rest,” participants are also prompted to ruminate when they are in the scanner. This allows Jacobs to better understand what is happening and how to intervene.
“We ask participants to come up with sad memories several weeks before the fMRI that will prompt them to ruminate. They are also given distraction prompts, like imagining a row of shampoo bottles,” says Jacobs. “We look at how they flip between rumination to focusing on a task, which is an important skill to have.”
Jacob’s rumination-focused CBT intervention focuses less on changing specific thoughts and more on how to recognize the process of thinking, such as triggers for getting stuck in a ruminative pattern. A trigger for a teenager to fall into rumination could be checking an ex’s Facebook page, which may cause them to compulsively wonder why the ex is no longer in love. The intervention aims to help the teen recognize the trigger and shift into a more productive way of thinking. Once recognized, they can move from asking “why” questions to “how” questions.
For example, if a teenager is checking Facebook they may be wondering, “Why doesn’t anyone care about me?” and want to feel connected. “Why questions don’t have concrete answers and tend to feed rumination,” says Jacobs.
Instead, Jacobs coaches teens to ask “how” questions, such as “How can I feel connected to someone right now? How can I feel less lonely?” “How” questions lead to more specific answers and are more likely to engage active problem solving.
Another component of the intervention is mindfulness training, which allows the teen to choose what to do next rather than be “pulled” by the habits of their brain. Jacobs explains, “It teaches people to be present. If you are ruminating, you are in the past. If you are worrying, you are in the future. But if you are present, what is happening to you at that particular moment usually isn’t that bad.”
Jacobs will follow the teens in her study for two years to determine how they are doing in their present environment and if they are meeting developmental milestones.
As a UIC Center for Clinical and Translational Science KL2 Scholar, Jacobs has had a very productive year. She has published five papers with mentor Dr. Scott Langenecker, a neuroscientist and neuropsychologist at UIC. “We have reached a place where there is synergy. He has a lot of fMRI data on depressed and nondepressed young adults, and I bring in the clinical application- how can this knowledge help us intervene today?”
Eventually Jacobs wants to teach teens skills that will allow them to stay well for years. Jacobs comments that the pre-pubertal years of 8-12 among girls in particular offer a critical window for intervention. “I am an interventionist, and when you look at these risk factors and you want to intervene, you have to do it young,” says Jacobs. “Research must ultimately help us figure out how treatment works and how to make it better.”
Rachel Jacobs was supported in part by the University of Illinois Center for Clinical and Translational Sciences KL2 Scholar Award via the National Center for Advancing Translational Sciences, National Institutes of Health (KL2TR000048). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.