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HannaAhrnberg

Depression in Adolescents

Essentials

  • Adolescence is normally considered to cover the ages from 13 to 22 years. Depressive feelings are common in adolescents. In the majority, this is a normal way of experiencing the growth and development of youth. It is therefore important to distinguish between depressive symptoms and clinical depression.
  • In the evaluation of depressive symptoms in an adolescent, the current stage of adolescent development and any life events that could possibly affect mood should be taken into consideration.
  • The diagnostic criteria of depression are the same for people of any age, but in an adolescent, depression can be masked by age-specific symptoms (such as arguing, pilfering, substance abuse) or fanatical pursuit of hobbies.
  • Early identification and treatment shorten episodes of depression, prevent recurrence and facilitate the continuation of age-appropriate adolescent development.
  • Mild or moderately severe depression can be treated in primary health care, primarily without medication.
  • Immediate reaction is necessary if there is acute self-destructiveness or risk of suicide.

Epidemiology

  • Depressive symptoms and depression increase from childhood to adolescence, particularly in girls. Similarly, grief reactions associated with loss deepen and suicide attempts increase from childhood to adolescence.
  • According to population studies, the prevalence of severe depression (Major Depressive Disorder (current) in DSM-III-R) is 3.4%, the prevalence of mild long-lasting depression (Dysthymia in DSM-III-R) is 3.2% and the life-time prevalence of severe depression is 13%. Depressive states are significantly more common in girls than in boys.
  • 40-80% of the severely depressed manifest some psychiatric comorbidity.
  • Severe depression is associated with an increased risk of suicide. The risk of self-destruction increases if substance abuse and asocial characteristics are associated with depression.
  • Untreated depression in an adolescent will probably continue into adulthood, and with prolongation of depression its treatment becomes more difficult.
  • Depression in adolescence predicts depression, anxiety disorders, self-destructiveness and substance abuse in young adulthood, poorer social coping, and poorer experienced quality of life.

Aetiology

  • According to the vulnerability-stress model, the development of depression is explained by the joint effect of susceptibility to depression and of the impact of current stressors, as well as a lack of protective factors.
  • Susceptibility to clinical depression is increased by underlying psychological factors (such as neglect, long-term conflicts in relationships), personality factors (such as obsessive-compulsive personality, temperament) and social factors (such as lack of social support, low socioeconomic status of the family).
  • The risk of becoming clinically depressed is also greater if some other member of the family has suffered from severe depression or bipolar affective disorder.
    • The contribution of heredity is estimated to be about 35%.
  • Onset of illness is often preceded by a negative life event or major setback (such as loss, divorce, transitional phase) experienced personally or in the person's immediate psychosocial environment.

Symptoms

  • Single depressive symptoms associated with normal development are transient and not associated with direct or indirect self-destruction, and the general ability of the young person to function is not impaired.
    • Such depressive symptoms are common in association with both psychological and somatic diseases and more common in adolescents than in children or adults.
  • Symptoms of depression that are normal for adolescence should be distinguished from clinical depression.
  • Clinical depression impairs the patient's functional capacity and causes significant subjective suffering.

Normative depression in adolescence (or grief associated with loss)

  • Feeling of sadness and loss, crying
  • Alternating moods: sadness-hate-joy
  • Sudden changes in self-esteem
  • Occasional worries about physical appearance
  • Minor physical symptoms
  • Occasional sleep disturbances
  • Resorting alternatively to primitive (e.g. denial, blaming others, splitting) or mature (e.g. rationalizing, suppression) defence mechanisms.
  • Social relationships are intact, as is the ability to enjoy food and hobbies and to become infatuated.

Clinical depression

  • Core symptoms (as in adults)
    • Low mood (for a minimum of two weeks)
    • Anhedonia (reduced ability to experience pleasure from things that used to bring pleasure)
    • Fatigue
  • Other symptoms
    • Difficulties in concentrating
    • Sleep disorders (prolonged sleep latency, waking several times a night, early morning insomnia, nightmares)
    • Changes in appetite and weight
    • Psychomotor retardation or pronounced restlessness
    • Feelings of worthlessness, guilt and shame, reduced self-esteem
    • Death wishes and thoughts of death (hopelessness, feeling of being at a dead end, having no vision for the future), self-destructive thoughts and behaviour (such as cutting), suicidal ideation, suicide plans or attempts
  • Symptoms that are typical for adolescents but atypical as regards the classification of depressive symptoms may complicate the assessment and detection of depression.
    • Boredom, sense of emptiness or constant irritation, anger
    • Changed behaviour and marked reactivity of mood manifesting as, for example, tearfulness, uncontrollable outbursts, sensitivity to criticism, withdrawal and, furthermore, impoverished relationships.
    • Somatic symptoms: headaches, abdominal pain or other vague pain with no evident cause found on examination, concern for one's own body to the point of hypochondria
  • The diagnosis can be made according to ICD-10 if at least two core symptoms and two other symptoms (mild: 4-5 symptoms; moderately severe: 6-7 symptoms; severe: 3 core symptoms and a total of 8-9 symptoms) occur simultaneously for a minimum of two weeks (for most of the day on most days of the week) causing subjective suffering and/or clear impairment of age-appropriate functional capacity.
  • In late adolescence, in particular, any hints of a delayed maturation process, inhibited age-appropriate development of autonomy or development of social withdrawal with regard to studies/employment should be considered when assessing depression in an adolescent.
  • Prolonged depression with decreased functional capacity negatively affects social interaction with peers as well as adults and the adolescent's development. Insufficient learning of social skills will jeopardise the central developmental tasks of adolescence, reinforcing a negative self-image.
  • A depressed adolescent uses mainly primitive defence mechanisms.

Examining and referring a depressed adolescent

  • Somatic causes for tiredness, apathy etc. should be excluded.
  • Somatic examination may also reveal indirect self-destructiveness, such as cutting.
    • If there are fresh marks of self-destructive behaviour, you should ask to see the marks and assess the nature of self-harm and any need for therapeutic measures.
  • Keep in mind that the young person may have a negative view of himself and may find it difficult to talk to a stranger. Reserve sufficient time for discussion.
  • Pose as direct questions as possible. Determine the duration and nature of the symptoms and their effect on daily life.
  • The assessment of depression requires a multifaceted approach.
    • When asking about symptoms, ask not only the adolescent (feelings, experiences, interaction) but also close adults (behavioural changes, symptoms and functional ability in various environments).
    • Find out about any changes related to school (concentration problems, disruptive behaviour, impaired school performance, absences, bullying or being bullied) and observations and feedback from school.
  • Self-destructiveness must always be assessed. Find out about
    • self-destructive thoughts
    • self-destructive behaviour
    • suicidal ideation and plans.
  • The structured Beck Depression Inventory (BDI) Beck as a Screening Method in Severe Depression, Dysthymia and other Affective Disorders of Adolescents (available against fee, see e.g. http://www.pearsonassessments.com/store/usassessments/en/Store/Professional-Assessments/Personality-%26-Biopsychosocial/Beck-Depression-Inventory/p/100000159.html [USA] or http://www.pearsonclinical.co.uk/store/ukassessments/en/Store/Professional-Assessments/Personality-%26-Biopsychosocial/Beck-Depression-Inventory-II/p/P100009013.html [UK]) can be used to assess the severity of depression. The Beck questionnaire is a useful screening tool for detecting depression although it produces a certain amount of false-positive results. Find out also about the availability of local modifications of the BDI specifically targeted at adolescents.
  • Other concomitant mental disturbances are relatively common (40-80%).
    • Of these, anxiety disorders, substance use disorders, eating disorders, behavioural and attention disorders are the most common.
    • As concomitant morbidity is associated with refractory depression, it is particularly important to identify any comorbidities and to treat them effectively.
  • Mild and moderate depressive states and grief reactions can be treated in primary health care. The primary forms of treatment are non-pharmacological methods and supportive discussions.
  • If the depression of an adolescent has a rapid onset, is associated with significant psychomotor retardation or psychotic symptoms, is prolonged or if symptoms of severe depression or acute self-destructiveness are observed, the young person should be referred to a specialist adolescent psychiatry unit.
    • While waiting for the appointment, take care of supporting the adolescent (maintain contact).
  • If there is acute self-destructiveness or if the adolescent is assessed as being at risk of suicide, the reaction must be immediate: telephone consultation of / referral for observation at a specialized care unit.
  • The diagnosis of severe depression, the planning and follow-up of treatment are carried out in specialized care.
    • Because a considerable proportion of early-onset depressive states (< 20 yrs) later develop into severe states of depression, it is essential to arrange long-term treatment, also taking into account other concomitant mental disorders.

Treatment Electroconvulsive Therapy in Young People, Tricyclic Antidepressant for Depression in Children and Adolescents

  • Mild or moderately severe depression
    • Primarily psychotherapeutic methods
    • Close cooperation with the parents and/or other close adults, and measures supporting parenting
    • Rehabilitation is also often necessary (e.g. school arrangements, social support).
    • Before starting psychotherapy, psychosocial support discussions are often needed, most typically provided by school psychologists, social workers or low-threshold mental health services that can be used without referral. The availability and procedures of low-threshold mental health services for adolescents vary from region to region.
  • Psychotherapeutic treatment in combination with medication appears to protect from self-destructive behaviour Psychological Therapies Versus Antidepressant Medication for Depression in Children and Adolescents, even though based on trials it is not possible to draw direct conclusions concerning the comparative superiority of psychological interventions, antidepressant medication or a combination of these.
  • Cognitive-behavioural therapy and interpersonal psychotherapy would appear to be effective in the treatment of depression in adolescents. There is also some evidence of benefits of mindfulness-based therapy, family therapy and brief psychodynamic psychotherapy as parts of acute treatment.
  • There are no controlled studies on long-lasting psychodynamic therapies.
  • In international guidelines, antidepressants are only recommended for severe symptoms and even then only in combination with psychotherapy.
  • The Finnish Current Care Guideline also suggests antidepressants if regular psychotherapy does not produce a response in 1-2 months (4-6 sessions) 15.
  • In severe depression, medication should be started at an earlier stage.
  • Temporary medication, such as melatonin, can be considered to alleviate symptoms, as necessary. Short-acting hypnotics or anxiolytics should be used with extreme caution and in very short courses only.
  • Selective serotonin reuptake inhibitors (SSRIs) are the most common choice for pharmacotherapy.
    • The primary option in the treatment of depression in patients below 18 years is fluoxetine. It is usually started in doses of 10 mg every morning, increasing the dose to 20 mg at 1-2 weeks. It takes typically about 4-6 weeks to achieve a response. Most patients benefit from doses of 20-40 mg.
    • If the response to fluoxetine is not satisfactory, replacing it by another SSRI can be considered; of these, sertraline and escitalopram are most commonly used in adolescents.
    • When starting pharmacotherapy or trying to find a suitable product and therapeutic dose, the adolescent must be followed up weekly. This need not, however, be by a doctor but can also be by a nurse with the required expertise.
    • Before beginning medication, an ECG should be taken because SSRIs have in some cases been associated with prolonged QT interval. An abnormal ECG rarely prevents starting SSRIs but a paediatric cardiologist or a cardiologist should be consulted first to establish, for example, the further follow-up procedure.
    • If the adolescent has had manic or hypomanic phases or there is a family history of bipolar affective disorder, any SSRI medication must be started under very close supervision and in combination with a mood stabilizer, and concurrent antipsychotic medication can be used if needed. This should be assessed primarily in specialized care.
  • Tricyclic antidepressants have not been shown to be more effective than placebo Tricyclic Antidepressant for Depression in Children and Adolescents, and they are not recommended for adolescents.
  • If antidepressant medication is started for an adolescent, it should be continued for at least 4-6 months after the alleviation of symptoms and withdrawn gradually.
  • Initiation and follow-up of medication should be carefully planned, bearing in mind that self-destructive impulses may increase in the initial phase of the treatment.

    References

    • Depression. A Current Care Guidelines. Working group appointed by the Finnish Medical Society Duodecim and Finnish Psychiatric Association. Helsinki: Finnish Medical Society Duodecim, 2020 (referenced 1 Oct 2022). In Finnish, abstract available in English http://www.kaypahoito.fi/en/ccs00062.
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