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Forum Mental Health Adoles Depr-NH2 31/10/2006 15:42 Page 1 Early detection vital in adolescent depression Depression is the most common psychiatric disorder in schoolaged teenagers, write Aileen Murtagh and Fiona McNicholas Table 1 YOUTH DEPRESSION IS underdiagnosed and undertreated. When parents are faced with resistant, belligerent, or hostile behavior from a teenage child, they often assume this is part of the normal turbulence of the teenage years. However, major depressive disorders are common in young people and frequently persist into adulthood. Due to the high risk of suicide, especially in young males, early detection and treatment is vital. Epidemiology Fleeting depressive symptoms are very common and increase with age. By the end of adolescence up to 20% may suffer from transient depression. Between 2% and 5% of adolescents experience a major depressive episode. A recent Irish survey of 723 school-aged teenagers found that depression was the most common psychiatric disorder in the group. The sex ratio in childhood depression is 1:1. By middle to late adolescence the female preponderance seen in adult depression is evident. Aetiology Causation is often multifactorial with interplay between genetic and environmental factors. There is frequently a genetic predisposition with a family history of a mood disorder. Genetic vulnerability may increase susceptibility to environmental factors, such as family conflict, loss of a parent, parental divorce and other adverse life events. Clinical presentation Adolescent depression often presents as academic underperformance, school refusal, low self-esteem, substance misuse, social isolation, frequent somatic complaints, behavioural problems or irritability. Adult criteria are used to diagnose depression in adolescents and are outlined in Table 1. Length of symptoms and whether they interfere with school work and relationships with friends and family is important in differentiating depressive symptoms from normal behaviour, including normal unhappiness, or from other diagnoses. Symptoms should be present for at least two weeks. The degree to which participation in normal academic and/or social activities is disturbed assists in differentiating severity of depressive episodes. Some interference with everyday functioning is consistent with a mild depressive episode. Considerable difficulties in functioning, and an increased number of depressive symptoms, indicates a moderate episode. Comorbidity Over half of adolescents with a depressive disorder will present with other psychiatric disorders. Anxiety disorders 50 FORUM November 2006 Symptoms of depression • Depressed mood • Loss of interest/enjoyment in normally pleasurable activities • Increased fatigue • Reduced concentration • Reduced self-esteem and self-confidence • Ideas of guilt and unworthiness • Bleak, pessimistic views of the future • Ideas/acts of self-harm or suicide • Sleep disturbance • Reduced appetite • Lack of emotional reactivity to normally pleasurable events/surroundings • Early morning waking (> two hours earlier) • Depression worse in morning • People commenting on psychomotor retardation/agitation • Weight loss • Marked loss of libido and dysthymia are particularly common. Dysthymia is chronic low-grade depression (for at least one year), but symptoms are not severe enough to be classified as a depressive disorder. Behavioural and somatisation disorders are also frequently seen. Substance misuse can co-occur and complicate treatment and prognosis. Differential diagnosis Other diagnoses to consider include dysthymia, adjustment disorder, bereavement reaction, substance misuse, bipolar disorder, eating disorder, early onset schizophrenia (negative symptoms) and organic disorders (eg. thyroid dysfunction, anaemia, epilepsy, etc). Approximately one-in-five adolescents with major depressive disorder will go on to develop bipolar affective disorder. Risk factors include adolescents with a family history of bipolar disorder, those presenting with psychotic symptoms or psychomotor retardation and those who develop hypomanic or manic symptoms on antidepressant medication. Treatment As with the treatment of any child psychiatric disorder, the treatment is multi-modal. Biological, psychological and social parameters need to be addressed (see Table 2). Psychological treatment The 2005 NICE guidelines state that young people with moderate or severe depression should be offered a psycho- Adoles Depr-NH2 31/10/2006 15:42 Page 2 Forum Mental Health Table 2 logical therapy as a first-line approach. This should be continued for at least three months. Factors such as patient choice, availability of trained therapists and family dynamics may influence choice of therapy. Cognitive behavioural therapy (CBT), interpersonal therapy for adolescents (IPTA), family therapy, psychodynamic psychotherapy, supportive individual and/or family work can be considered. It is important that psycho-education is carried out with both the adolescent and the family. CBT entails 10-20 weekly sessions to modify and monitor automatic negative thoughts and distorted thinking. Behavioural strategies include encouraging social activities. CBT is becoming more widely available. A new CBT training course is commencing this year in UCD for professionals working specifically with children and adolescents. IPT-A addresses interpersonal conflict in current relationships, which can contribute to depressive symptomatology. Psychodynamic therapy is a long-term therapy which establishes links between current symptoms and functioning to past events. It aims to resolve internal conflicts related to early experiences. Social treatment Liaison with the school is often necessary (with parental consent) to address issues such as bullying or specific learning difficulties, which may be precipitating or maintaining episodes of depression. It may be necessary to recommend treatment of mental health problems in the family, eg. maternal depression. Contact details of local support groups, such as AWARE, should be given. Biological treatment The role of antidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs), in adolescents is the subject of much debate. Concern has been expressed regarding a possible increase in suicidal ideation and behaviours with SSRI use in young people (as in adults). The risk appears to be increased in those who are non-compliant, experience behavioural activation (SSRI-induced restlessness, hostility or irritability) or switch to a manic state. Antidepressants are not licensed to treat childhood depression. The IMB recommends that SSRIs, SNRIs (serotonin norepinephrine re-uptake inhibitors) and TCAs (tricyclic antidepressants) should not be prescribed in children under 18 years. The CSM in the UK contraindicates the use of SSRIs, except fluoxetine (Prozac), and the related antidepressant venlafaxine (Efexor), in the same age group. However, it is recognised that clinicians make decisions for patients on an individual basis. In general, cautious prescribing in children under 18, in a specialist setting, is advised. Clinicians should refer to regulatory bodies for upto-date advice. Antidepressants may be considered in cases where there has been no response to psychological therapy, where psychological therapy is inaccessible or for patients with moderate or severe depression. When considering antidepressant treatment, ask about a history of suicidal behaviours or manic symptoms in the family or patient. The risks and benefits of treatment should be evaluated and the family should be appraised of these. Fluoxetine has the strongest evidence of efficacy from clinical trials. Close review is necessary and the patient should be monitored for side-effects, clinical worsening, increased suicidal ideation/acts, hypomanic/manic symp- Treatment of depressive episodes • Mild depression Psycho-education Supportive therapy Address precipitating factors (eg. extra resources in school if learning difficulties) • Moderate depression As above, plus CBT or IPT If unresponsive, consider fluoxetine • Severe depression Psycho-education Combine CBT/IPT and medication toms, agitation, irritability and unusual behaviour changes. The Maudsley Guidelines state that fluoxetine is the medication of choice if psychopharmacology is deemed necessary. The starting dose is usually 5mg-10mg daily in liquid form. In non-responders, an alternative SSRI can be considered by specialists. TCAs, such as amitriptyline (Triptafen/Lentizol), imipramine (Tofranil) and nortriptyline (Allegron) have been used, but lack a strong evidence-base in this age group and have numerous side-effects, including cardiotoxicity. Regular ECGs are needed. Antidepressants should be continued for six months following the restoration of euthymic mood. In cases of multiple episodes of depression or complicated episodes (eg. comorbid psychotic symptoms) treatment should be continued for at least a year. Slow tapering of the dose should then occur over 6 to 12 weeks to minimise discontinuation symptoms. There is no strong evidence to date to support the use of fatty acids in adolescent depression. ECT can be considered by child and adolescent psychiatrists in severe life-threatening depression or in treatment-resistant cases. Prognosis A major depressive episode in an adolescent can last six to nine months. Recurrence is common, especially for children who experience a major depressive episode superimposed on dysthymia. Adolescent depression carries an elevated risk of adult depression and persistent interpersonal difficulties. There is a six-fold increase in adult suicide rates. Conclusion The consequences of not identifying and treating depression in adolescence can be grave. Mortality rates are increased due to an elevated risk of suicide and poor lifestyle choices, such as substance misuse. Greater public awareness and development of collaborative relationships between health professionals are needed, so that adolescents and their caregivers seek help and receive appropriate treatment at an early stage. Referral to child and adolescent mental health services should be considered for children with moderate to severe depression, adolescents presenting with suicidal ideation/ intent, comorbidity, treatment-resistance and those requiring medication or multidisciplinary input. Aileen Murtagh is a registrar in Dunfillan Young Person’s Unit, Lucena Clinic, Dublin and Fiona McNicholas is a consultant child and adolescent psychiatrist at the Lucena Clinic and Our Lady’s Hospital for Sick Children, Crumlin FORUM November 2006 51