Managing and preventing depression in adolescents
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c209 (Published 22 January 2010) Cite this as: BMJ 2010;340:c209
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Thapar and colleagues clinical review on assessment and management of
adolescent depression although mainly targets non specialists (GPs in
primary care) but it may be a great opportunity for clinicians from child
and adolescent health services (CAMHS) to update them on the topic, which
is considered to be a major public health and clinical priority by some1.
Authors provide useful advice, as one of the tips for non-specialists
to refer patients with moderate to severe depression to CAMHS for further
management rightly but their instruction on treating the same gives the
impression that they are advocating for antidepressant medication as first
line of management, which may not be the intention. Evidence from the two
studies2-3 they have quoted is in the favors of Fluoxetine (61% response
rate) and evidence to get some benefits after adding cognitive behaviour
therapy (CBT) is mixed and British study, ADAPT2 even shows less response
with combination of fluoxetine with CBT (53% improved or very much
improved) in comparison with fluoxetine (61% response rate) alone.
NICE guidelines on depression in children and young people4
recommends specific psychological therapies in the form of individual CBT,
interpersonal therapy or short-term family therapy for moderate to severe
depression (for at least 3 months) as a first-line treatment. It is not
rare to receive referrals from GP colleagues for adolescent suffering with
depression and is often on antidepressant without any consideration given
to any psychological therapy or even guided self help or non-directive
supportive counseling, as suggested by the authors.
We agree that psychological therapies are not widely available, even
within CAMHS, due to shortage of staff, funding issues, long waiting
lists, funding and training issues of staff, to mention a few. It is
crucial to make a case for further availability of psychological therapies
and carefully designed trails to test their usefulness in research and
clinical settings in children. Children and young people are different
from adults and hence our approach to deal with their difficulties, in
order to avoid the same mistake as in treating adult depression with a
‘pill’ by GPs and psychiatrists and ignoring the evidence for the role of
psychological therapies (often due to lack of availability).
References:
1.Thapar A, Collishaw S, Potter R, Thapar AK. Managing and preventing
depression in adolescents. BMJ 2010; 340:c209
2. Goodyer I, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S,
et al. Selective serotonin reuptake inhibitors (SSRIs) and routine
specialist care with and without cognitive behaviour therapy in
adolescents with major depression: randomised controlled trial. BMJ 2007;
335:142.
3. Treatment for Adolescents with Depression Study (TADS) Team. The
treatment for adolescents with depression study (TADS): outcomes over 1
year of naturalistic follow-up. Am J Psychiatry 2009; 166:1141-9.
4. Depression in children and young people: identification and
management in primary, community and secondary care. NICE guidelines-CG28,
Sep 2005
Imran Mushtaq, Locum Consultant Child and Adolescent Psychiatrist,
Northampton CAHMS, 8-Notre Dame Mews, Northampton NN1 2BG U.K
Email: imranmushtaq@doctors.org.uk
Mohammad Zafar Iqbal, Child & Adolescent Psychiatrist
Email: zafar71ie@hotmail.com
Competing interests:
None declared
Competing interests: No competing interests
Managing depression in adolescents: A barrier in primary care?
Dear Editor
Thapar et al’s 1 comprehensive clinical review describes the
importance of identifying adolescent depression given the serious adverse
implications of significant under-diagnosis and treatment, including the
impact on current and future functioning, high rates of recurrence, and
raised risk of suicide. They highlight the key role for primary care in
the detection and initial management of depression in adolescents and
allude to first line pragmatic psychosocial approaches. However, attempts
to improve the involvement of primary care in identification and
management are impeded by concerns about the ‘medicalization’ of
depression 2,3 .
Those favouring demedicalization of adolescent depression suggest
that current diagnostic criteria fail to differentiate normal sadness or
‘common emotional turmoil’ in response to stressful events from ‘genuine’
depressive disorders; they are concerned about the high false positive
rate that may result from mass screening programmes using questionnaires;
they fear stigmatisation through targeted intervention for milder symptoms
by health professionals, and favour broader treatment options such as
school and family interventions 2,3.
In response, Brent’s 4 recent cogent editorial acknowledges the
limitations of current diagnostic criteria but highlights empirical
evidence that clinical interview can distinguish depressive disorder even
in the context of stresses such as bereavement, when guided by
symptomatology, severity, functional impairment as well as a personal and
family history of depression. Furthermore he presents evidence to
demonstrate that life events and depression are not independent, but
rather that psychological disorder arises from the interaction of stress
and personal vulnerability. This means that using external stressors alone
to account for symptoms of sadness is insufficient and inaccurate, since
when these feelings are enduring and associated with impairment they are
associated with increased risk of future episodes of depression.
The NICE guidelines on depression in children and young people could
be considered to add further confusion by recommending depression
screening in primary care by targeting those exposed to single recent life
events such as severe disappointments; in addition to the fact that young
people do not usually present to primary healthcare services with stress
reactions to distressing events, there is little evidence to support the
benefit of this intervention 5.
Primary care practitioners’ fears about the medicalization of
depression perpetuate the failure to explore psychological problems in
young people even when these are perceived to be present 6,7. This limits
their ability to both identify severely depressed young people (including
those with suicidality who require referral for specialist intervention)
and provide support for those with mild to moderate symptoms. Efforts to
enhance practitioners’ confidence in talking to young people about their
emotional state, skills in identification of depressive disorder and
therapeutic techniques for managing depression might allay these fears.
Our collaboration between child psychiatrists and GPs has developed,
piloted 8 and feasibility tested a programme to address this. The TIDY
programme (Therapeutic Identification of Depression In Young People) 9 is
a package of training and tools developed to support primary care
practitioners to engage young people (who almost exclusively present with
physical complaints), in conversations about their emotional well being.
Guidelines are given to facilitate identification of depression as opposed
to ‘normal moodiness’ and a repertoire of intervention strategies are
provided that can be offered within the consultation for milder cases;
TIDY implementation also helps to differentiate depressed young people
requiring specialist referral.
Since adolescents attending primary care have increased rates of
depression (usually unrecognised)10 and primary care is the only medical
setting to which they have ready access, we have worked to develop a
‘single dose’ intervention that provides advice on self help strategies
and encourages adolescents to seek support from within their family and
wider social environment. Preliminary analysis of the feasibility study
suggests that selective, opportunistic use of TIDY is followed by a small
but statistically significant increase (from a very low baseline) of
recognition of depression in young people attending general practice. The
therapeutic components of TIDY are used by practitioners selectively in
consultations and are acceptable to young people. Further research is
required to further evaluate the clinical and cost effectiveness of this
approach. Additionally the views, wishes and experiences of young people
themselves, including the healthy, the moody and the seriously depressed
should be included in the debate about which interventions are most
helpful.
Reference List
(1) Thapar A, Collishaw S, Potter R, Thapar AK. Managing and
preventing depression in adolescents. BMJ 2010; 340(jan22_1):c209.
(2) Horwitz AV, Wakefield JC. Should Screening for Depression Among
Children and Adolescents Be Demedicalized? Journal of Amer Academy of
Child & Adolescent Psychiatry 2009; 48(7).
(3) Finlayson J. Depression in younger people. British Journal of
General Practice 2009; 59:542.
(4) Brent DA. Medicalize depression, not sadness. J Am Acad Child
Adolesc Psychiatry 2009; 48(7):681-682.
(5) Hodes M, Garralda E. NICE guidelines on depression in children
and young people: not always following the evidence. Psychiatric Bulletin
2007; 31(10):361-362.
(6) Martinez S, Reynolds S, Howe A. Factors that influence the
detection of psychological problems in adolescents attending general
practices. British Journal of General Practice 2006; 56:594-599.
(7) Iliffe S, Williams G, Fernandez V, Vila M, Kramer T, Gledhill J
et al. General practitioners? understanding of depression in young people:
qualitative study. Primary Health Care Research & Development 2008;
9(04):269-279.
(8) Gledhill J, Kramer T, Iliffe S, Garralda ME. Training general
practitioners in the identification and management of adolescent
depression within the consultation: a feasibility study. J Adolesc
2003;245-250.
(9) Therapeutic Identification of Depression in Young People:
Identification and Treatment Manual. 2009.
http://www1.imperial.ac.uk/resources/E1A08677-A38D-49AB-A138-F1E1C97178EF/
(10) Kramer T, Garralda ME. Psychiatric disorders in adolescents in
primary care. Br J Psychiatry 1998; 173:508-13.:50
t.kramer@imperial.ac.uk
Competing interests:
None declared
Competing interests: No competing interests