Current evidence supports a staged approach to treatment.13 For young people, especially those with milder presentations, effective first-line treatment could include providing information, suggesting dietary and lifestyle modifications, and encouraging increasing physical activity and exercise.13, 18
For presentations of mild to moderate anxiety or depression CBT has demonstrated benefits and is considered appropriate first line treatment.13,19 Depending on the young person’s personal preferences and needs, interpersonal therapy and non-directive supportive therapies are other evidence-based options for psychological support.19 If there are known waiting periods for accessing psychology or other therapies, work with the young person to explore interim approaches. These could include online mental health programs and resources that can help the young person start to understand their symptoms and distress, while providing some initial support.20
Other useful management strategies can be providing youth-friendly information on mental health and discussing the pros and cons of different treatment approaches.
If symptoms of depression or anxiety are severe, or psychological treatment is not possible or not effective, then use of a medicine may be an option. Any use of medicines should be a thoughtful decision made jointly with the young person (and where appropriate their parents or other carer). “Start low and go slow” is a good approach, reviewing the patient regularly to assess their response to, and tolerance of, any drug treatment (Figure 2).
SSRIs, for example, are more effective in moderate to severe depression and anxiety, but risk increasing suicidal thoughts and actions in young people. Increasing doses above the “standard” dose does not result in increased efficacy, but may lead to increased numbers dropping out of treatment due to side effects.21
Other antidepressants, such as SNRIs, or tricyclics and tetracyclics (mirtazapine) are not recommended for young people (particularly those under 18yrs), other than perhaps in specialist practice, due to potential worsening of outcomes.