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Adoles Depr-NH2
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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
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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-
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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
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