Summary

Approximately 20% of young people will have an episode of depression in a 12-month period. Depressed young people may present with vague complaints, and health professionals should be aware of the possible diagnosis. The first part of successful management is making the diagnosis based on a comprehensive assessment of the depressive symptoms. Psychological management and cognitive behavioural therapy are usually key elements in the treatment of adolescent depressive disorders. Although there is no clear evidence to show the effectiveness of antidepressant drugs in young patients, their judicious use is indicated when there is no response to psychological treatments, and symptoms persist.

Introduction
The National Health and Medical Research Council (NHMRC) has published a comprehensive clinical practice guidelines booklet on 'Depression in young people'.1 Shorter booklets 'Depression in young people: a guide for general practitioners' and 'Depression in young people: a guide for mental health professionals' are also available.* What are the key messages in these publications?

Clinical presentation
Young people are defined as aged 13-20 years. A depressive disorder is a persistent depression of mood which can seriously affect social, emotional, educational and vocational life. It is also an important predictor of suicidal behaviour. Although estimates of prevalence vary, a depressive episode affects between 14-30% of young females and 13-17% of males in a 12-month period, with 2.7-8.9% of females and 1.6-9.0% of males suffering a more serious major depression. Depression definitely occurs in children younger than 13 years of age, but becomes progressively more prevalent after puberty and reaches adult levels in the late teens. It is often unrecognised and under-treated (Table 1). Depression has a number of associated risk factors such as a history of anxiety, conduct disorder and substance abuse, or a family history of depression. Other risk factors include being female, stressful life events such as death of a parent and family conflict, and repeated experiences of failure and criticism. The experience of good peer and parental relationships and success at school or in employment act as protective factors.

Table 1

Symptoms of depression

Persistent depressed mood, unhappiness and irritability
Loss of interest in recreation activity and friends
Loss of energy and concentration
Deterioration in school or work performance
Change in appetite with corresponding weight change
Disturbed sleep
Thoughts of worthlessness and suicide with increasing risk of attempts with age
Somatic complaints e.g. headache, abdominal pain

Assessment
Depressed young people usually present to medical services with vague complaints. Doctors should be alert to the possibility and make direct and positive enquiry about the emotional state and mood. Assessment and diagnosis require establishing a positive relationship in which the young person feels secure regarding confidentiality and knows that they are your patient (Table 2).

The differential diagnosis of depressive disorder includes bereavement, depressive reaction to an acute stress (adjustment disorder) and schizophrenia or associated psychosis. Depressive disorder can also commonly occur together with other psychopathological disorders such as attention deficit hyperactivity disorder, conduct disorder and anxiety disorders.

Table 2

Assessment of depression

Interview the young person separately and together with the parents and family

Assess current symptoms, level of functioning and mental state including suicide risk

Explore developmental, psychiatric and medical history, recent stresses, use of medication, alcohol and illegal drugs, sexual history including pregnancy

Understand the family situation (structure, contact and support), and cultural and peer group issues

Depression rating scales may assist with diagnosis and response to treatment

Information from teachers or employer (with patient's consent)

Other investigations such as cognitive assessment might help define the co-existence of learning problems

Physical examination to exclude complicating or contributory physical illness such as thyroid disease

Assessing the risk of suicide is essential. This involves asking about any previous suicide attempts, the experience of a sense of hopelessness/helplessness and having no future, current suicidal ideation and the presence of a plan and means. A history of impulsive risk-taking behaviour and a reluctance to seek help, particularly in young males, increases the risk. Referral to specialist services is required when the young person is suicidal, when the depression is severe with psychotic or bipolar features, and when treatment has been unsuccessful.

Treatment (Table 3)
Successful management usually requires a combination of approaches, but begins with the assessment process that leads to a positive diagnosis. Providing the young person with comprehensible information regarding depression, involving the family and maintaining contact are crucial elements. Psychological treatments such as counselling and cognitive and behavioural methods are often effective. When symptoms persist or are severe, despite these interventions, the judicious use of antidepressant medication may be necessary.

Cognitive behaviour therapy
In combination with parental support and skills training, cognitive behaviour therapy has been shown to be an effective treatment. It involves a combination of relaxation training, modelling and reinforcement of confident behaviours, formulating positive thoughts (cognitions) and the experience of rewarding structured tasks and social activities and skills chosen to match the individual psychological needs of the young person.

Interpersonal therapy
This is a structured form of insight-oriented psychotherapy and involves the systematic identification and resolution of relationship problems. It has been effective in open trials, but further controlled studies are required.

Family therapy
Family therapy helps reduce family dysfunction and conflict which are risk factors for depression. However, there have been no studies to show that family therapy has a direct effect on depression.

Antidepressants
There have been no controlled trials of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) that provide clear evidence of their effectiveness in young people. However, there is also no clear evidence that antidepressant drugs are ineffective. Some open trials of SSRIs have shown recovery. Young people can experience intolerable adverse effects with TCAs and the cardiotoxic effects are dangerous in overdose. The SSRIs are reported to have fewer adverse effects than the TCAs, but can produce nausea, restlessness, drowsiness, insomnia, irritability, tremor, dry mouth, decreased appetite, sweating, memory impairment and sexual dysfunction. More seriously, they may cause hypomania and excitement, and suicidal ideas and behaviour. There is no evidence for or against the effectiveness of reversible or irreversible MAOIs in the treatment of depression in adolescents. The adverse effects of these drugs in teenagers are unknown.

Table 3

Management of depression

1. Establish a supportive, positive, confidential doctor-patient relationship

2. Undertake a clinical diagnostic assessment (Table 2) and feed back your conclusions to the young person and family

3. Decide if symptoms warrant your intervention or specialist referral or hospitalisation

4. Arrange appropriate support from family, friends, community agencies and provide 24-hour telephone crisis contact number

5. Provide a practical and appropriate treatment plan to match resources and the specific needs of the young person which may include:

– cognitive/behavioural interventions
– family therapy for grief, conflict and parenting skills
– psychotherapy such as counselling and interpersonal therapy
– consultation with school/community groups to facilitate experiences of success
– antidepressant medication, particularly the SSRIs

6. Follow-up to facilitate treatment compliance and re-integration back into school and community life

There is evidence that the pharmacokinetics of psychotropic drugs are different in young people compared to adults. The response to the drugs may also differ. For example, the half-lives of TCAs are generally shorter in young people than in adults and steady state plasma levels can vary widely in children at the same mg/kg dose. Therefore, controlled studies of the efficacy of antidepressants in adolescents are necessary. Until more is known, antidepressants should continue to have a secondary role in the treatment of adolescent depression, provided the young person is involved in the decision to prescribe, understands the possible adverse effects and expected benefits, and is regularly reviewed. If drug treatment is used, then it should form part of a broader psychotherapeutic and supportive management plan. There is a role for the use of lithium and carbamazepine and sodium valproate in the treatment of bipolar disorders, but that should only be in consultation with a specialist psychiatrist.

Special issues
The special needs of young people from rural areas, from Aboriginal and Torres Strait Islander communities and from non-English speaking backgrounds are still poorly understood. Their special circumstances may place them at particular risk of depression. Young people with chronic medical illnesses, an intellectual disability and those who are in custody or who are homeless are known to have a higher prevalence of depressive illness and may require special attention from general and mental health services.

Conclusion
The NHMRC guidelines highlight the need for general practitioners to have a high index of suspicion regarding depression when consulted by young people, particularly if they present with a problem which has some associated psychological adjustment difficulty. General practitioners are encouraged to assess young people for the presence of depressive symptoms and, in particular, to be active in asking questions regarding suicidal ideas and risk. They can then initiate a process of information support and treatment for the young person and the family.

There is evidence of improved mental health outcomes for patients when general practitioners have received training and assessment and psychological treatment skills such as counselling and cognitive/behavioural techniques suitable for primary care settings.

* Orders can be placed for any of these 3 publications by telephoning AGPS Tele services - 132 447.

References

  1. National Health and Medical Research Council. Depression in young people: clinical practice guidelines. Commonwealth Department of Health and Family Services, Canberra: Australian Government Publishing Service, 1997.test que