Depression in adolescent

Question 1

Epidemiology

Answer 1

Major depression affects 3-5% of children and up to 24% adolescent. Atypical depression is common

Question 2

Risk factors

Answer 2

Positive family hx, female sex, developmental stage and hormonal changes, history of abuse or neglect, stressful life events, chronic illness

Question 3

Depression vs normal sadness

Answer 3

The diagnosis of major depressive disorder occurs via thorough and developmentally informed assessment, the potential use of assessment tools, and use of diagnostic criteria within the well-recognised diagnostic classification systems. The assessment aims to be as developmentally and systemically informed with important collateral sources including parents/carers, schools included. Confidentiality and privacy are particularly important to young people and need to be addressed early in the first session.
It is important to differentiate between normal emotions and depression as a disorder (i.e. not to medicalise normal sadness). The most important distinction is that depression is associated with impaired functioning, demonstrated by a diminished competence in completing the tasks of daily living, maintaining relationships with friends and family, and ability in school and work environments. These changes are accompanied by persistent, conspicuous changes in mood or behaviour, together with a relative lack of responsiveness to experiences that might normally bring pleasure or relief. Many young people when under stress will experience sadness, irritability and a depressed mood, which do occur within the context of the constellation of symptoms and signs which are evident in a major depressive disorder.
Depressive disorders in young people are often complex and heterogenous. Many factors besides symptoms must be considered. Many young people with depression do not ‘fit’ neatly into a single diagnostic category.
Co-occurring conditions are common in depressed adolescents (AACAP 2007; Zalsman et al 2006). Depending on the setting and source of referral, 40–90% of young people with depressive disorders also have other psychiatric disorders, with up to 50% having two or more co-occurring diagnoses (AACAP 2007):
 anxiety is often a precursor of depressive disorder and is the most frequent co-occurring condition;
 disruptive behaviour disorders such as attention deficit hyperactivity disorder, oppositional defiant
disorder and conduct disorder commonly co-occur with depression;
 depression increases the risk of other non-mood psychiatric problems such as eating disorders and substance misuse.

Question 4

Difference between depression in young and older adult

Answer 4

Overall, the symptoms, course and outcomes of depression are similar in adolescents and young adults to those in older adults. There are some specific differences, however, that have implications for assessing and treating depression in young people:
 developmental phases (cognitive, social and emotional) are more relevant in young people;
 in adolescents, mood may be described as irritable or cranky rather than sad;
 considering the wider context, particularly the family and educational (school, traineeship, university) environment, is vital in assessment and treatment of young people;
 current knowledge suggests that the biological causes of depression increase as people age;
 psychosocial adversity may be relatively more prominent in younger people with depression;
 associated anxiety symptoms (e.g. fear of separation or reluctance to meet people) and physical symptoms (e.g. aches and pains) are more common in depressed youth than in older adults;
 while symptoms of depression tend to be similar in young people and older adults, depressed young people are more likely to present initially with other problems (e.g. substance misuse, violent or destructive behaviour, eating disorders and absences from school);
 while young people have higher overall rates of substance misuse, older adults are more likely to have substance dependence and therefore more prone to substance-induced mood disorder; and
 the types of treatments that are effective and acceptable differ, particularly in the area of medications.

Question 5

Depression and school performance

Answer 5

Adolescent depression can have a significant negative impact on school performance and consequently produces maladaptive outcomes in terms of subsequent education and occupational functioning. Several key symptoms of depression, such as impaired ability to concentrate, loss of interest, poor initiative, psychomotor retardation, low self-esteem, sense of worthlessness as well as social withdrawal may significantly disturb cognitive performance and diminish initiative in learning. School attendance may decline, thus further compromising academic achievement and further hinder a sense of self mastery and optimism.
Depression may impair cognitive functioning because the depressed adolescent concentrates on depressive thoughts and interpretations instead of the actual tasks, or because depression directly blocks cognitive resources, or due to both reasons.
The negative reactions of teachers and peers may also cause learning problems via paying attention to the depressed adolescent’s behaviour and emotional problems instead of learning Failures and negative feedback are likely to further exacerbate the depressive cognitive style typical of depression or strengthen depressive thought(s) promoting learned helplessness, passivity and avoidance.
Some research has targeted the associations between depression and students’ motivational beliefs and attitudes in coping with the responsibilities of school. Underestimation of academic competence and low achievement expectations have been reported to be associated with adolescent depression.
The direction of causality is often complex with poor academic achievement and associated school based difficulties often instrumental in the onset or worsening of a depressed mood and disorder.
A variety of associated comorbidities may contribute to the onset or maintenance of the depression, including substance abuse and dependence.

Question 6

Treatment & management

Answer 6

Therapeutic engagement and treatment alliance appear to be particularly important in young people.
As with adult patients, accurate formulation and treatment planning are important. Psychoeducation, including information and advice on lifestyle factors, including diet, exercise and sleep, are integral to successful recovery.
Cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT) should be considered as first‐line treatment for adolescents with major depressive disorder.
The use of anti-depressant medication in young people is complicated by the reported increase in suicidal thinking in a subset of young people taking these medications. SSRIs are not recommended for treating adolescents or young adults with mild depression. In moderate to severe depression, anti-depressants can be considered, particularly if psychological therapies are unavailable or not appropriate. If prescribed, close monitoring is required.
Family therapy is indicated if family discord is a significant contributor to the presenting difficulties and appropriate consent and agreement has been solicited from the young person.
Schools and support of students with depression
Australian secondary schools have an important role to play to emphasise promotion and prevention as
well as early intervention strategies for students with depression. This is reflected in current approaches that encourage all members of the school community to contribute to an environment that promotes positive mental health and reduces common risk factors for depressive symptoms, such as bullying.
Mental health disorders, including depression, can be targeted at several levels within the school community. School leadership, working with staff with mental health expertise, can support a whole-of-school approach by:
 developing clear policies, processes and protocols for school staff with respect to their roles in supporting student mental health, including individual students who may be having problems.
 providing opportunities for staff to receive basic training in understanding and responding to common student mental health issues;
 identifying and promoting information on youth mental health to the broader school community, particularly information on local service providers, and credible online resources, and evidence-based mental health programs;
 developing strong links with local service providers to improve pathways for students and families seeking external support;
 developing strategies for keeping students experiencing mental health problems engaged in their schooling and other activities.
Schools can play an important role in developing student resilience by promoting a school culture that emphasises supportive relationships and builds a student’s sense of belonging, and by providing opportunities for students to develop social and emotional competencies.
A range of professionals either inside or outside the school undertakes assessment and management of individual students experiencing depressive symptoms. These include (among others) psychologists, guidance officers, counsellors and youth workers. Specific roles often vary, even within individual professions. Ideally, professionals working with individual students experiencing difficulties (and their families) should have guidelines to support their work that correspond to their education and training.
Specific training for school staff may occur in relation to responding to deliberate self- harm (DSH). Schools will often have clearly defined policies and protocols for responding to, and supporting young people who present with deliberate self- harm. The policies and procedures can include such things as:
 Identifying DSH.
 Assessing DSH.
 Designating specific individuals within the school to serve as a point person for coordinating the response to an episode of DSH.
 Identifying the issues surrounding confidentiality and the circumstances when parents are to be contacted.
 Crisis management plans.
 Determining when and how to issue an outside referral to a specialist mental health team.
 Identifying external referral sources.u  Ongoing education of staff.
 Supporting others who may be affected within the school.
 Managing the risk of the spread of DSH within the school community.
Psychiatric consultation within schools
The predominant model utilised by psychiatrists and other mental health professionals when working with schools is a consultation/liaison model. The success of this model of professional-to-professional communication depends on cross-disciplinary communication skills in addition to specialty clinical knowledge when working in schools. Confidentiality issues need to be considered, with consent provided by the young person/family before the consultation is to occur. At times the young person will be present during the meeting, or for a part of the meeting. This will need to be negotiated.
The extent and quality of clinical information disclosed by the psychiatrist during the meeting needs to be carefully considered and will represent a reasonable balance between providing information to the school professional which will enhance their understanding and hence capacity to assist the young person, against the need to keep personal and clinically sensitive material private.
The acknowledgement of differing but equally important set of expertise’s creates the foundation for the meeting. The school personal become an important source of collateral information, enabling a more holistic picture of the young person as they exist within their natural ecologies. Important information regarding the young person’s functioning, including academic, social and personal can improve diagnostic validity and inform treatment planning. The schools relationship to the young person’s family/carers is of great importance and an important predictor of academic and school engagement.
A specific plan may be instituted by a school to enhance support to the young person. The plan is ideally negotiated and therefore meaningful to the young person. Specific aspects to the plan can include:
 Consideration of work/subject load and whether a reduced load, including a temporary reduction, is warranted.
 Consideration of subject choices and in particular whether any specific subjects are causing a
disproportionate amount of stress.
 Well defined plans for dealing with “bad days”, including any strong urges to self-harm.
 Well identified support people at school who may be consulted if required.
 Regular case conference meetings with health/educational/family involvement to monitor progress, exchange information and address any issues as they arise.
 Regular meetings between the young person/family and teachers to monitor school progress and facilitate timely problem solving.
 Encourage any factors promoting resilience and recovery, including any extracurricular activities.