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Adolescent depression

Scope of the guidance

This EGP Update item summarizes recent guidance on the management of depression in young people. It covers the recognition and diagnosis of depression in adolescents presenting in primary care and the various treatment options available to treat adolescent major depression including drug therapies and cognitive behavioural therapy (CBT). There is guidance on when to refer to secondary or tertiary services and what services should be available. Management of psychosis, anxiety and other mental health issues are not considered.

Source

Dubicka, B, Wilkinson P. Evidence-based treatment of adolescent major depression. Evid Based Ment Health 2007; 10(4): 100-2 http://ebmh.bmj.com/cgi/content/extract/10/4/100

Hazell P. Depression in children and adolescents. 

http://clinicalevidence.bmj.com/ceweb/index.jsp (subscription required)

National Institute for Health and Clinical Excellence.  Depression in Children and Young People Identification and management in primary, community and secondary care. National Clinical Practice Guideline Number 28. London: NICE; 2005. www.nice.org.uk/nicemedia/pdf/cg028fullguideline.pdf

Key points

1. Incidence and natural history

• Estimates of prevalence of depression in children and adolescents range between 2-6%. Most episodes last 7-9 months and nearly half relapse within two years; and as many as two thirds relapse within five years.
• The risk of depression occurring in adolescence is increased by family and social circumstances such as single parent families, low income, unemployment, depression in a parent and drug and alcohol abuse in parents. The incidence is higher in young people looked after in social care.
• Milder degrees of ‘sub-threshold’ depression are also common and these can be difficult to differentiate from normal transient mood disturbances in adolescence. Adolescent dysthymia is characterised by chronic low mood, a tendency to brood, low self-esteem and general gloominess. Young people with a history of milder depression or dysthymia may be at increased risk of developing clinical or major depression.
• Most major depression in adolescence occurs against a background of long-standing psychosocial and family problems. School refusal, behavioural problems and self-harm are common features.

2. Screening and diagnosis

• Self-report inventories used in assessment of depression in adults (e.g. PHQ-9) are not helpful in children and young people. The mood and feelings questionnaire (MFQ) has been developed for use in child and adolescent mental health settings, but has not been validated for use in general practice populations.
• Moodiness, unpredictability and tearfulness are common in adolescence and are not symptomatic of depression. Look for pervasive low mood with social withdrawal, inattention to physical appearance, reduced academic interest and performance, self-harm. Aggression and promiscuity sometimes occur.

• Depression is diagnosed by finding symptoms of low mood AND/OR instability PLUS anhedonia (total loss of feeling of pleasure in acts that normally give pleasure) AND/OR tiredness along with:
  • disturbed sleep
  • poor concentration or indecisiveness
  • agitation or retardation of movements
  • excessive guilt or self blame
  • decreased/increased appetite
  • low self-confidence
  • suicidal thoughts or acts

  Where:

  • mild depression: 4 symptoms
  • moderate depression: 5 or 6 symptoms
  • severe depression: 7 or more symptoms

  All the symptoms should persist throughout the day (although some diurnal variation may occur) and last for two or more weeks.

3. Organisation of services

The NICE guidance envisages four tiers of care:

GPs will refer on to tiers 2 and 3 (see www.nice.org.uk/nicemedia/pdf/cg028fullguideline.pdf) if:

• depression with ≥ 2 risks for depression
• depression with multiple risk histories in other family members
• mild depression not responded to interventions in tier 1 after 2-3 months
• moderate/severe depression
• recurrence of depression in those with previous identified moderate or severe depression
• unexplained self neglect ≥ 1 month
• actively suicidal ideas or plans

4. Treatment

• Mild depression: where symptoms are short-lived and there is good family support, watchful waiting within primary care is suitable. Offer follow-up to provide general support to the patient and family and check for deterioration. Self-help materials and simple advice regarding sleep hygiene, regular exercise and nutrition are also useful. Psychological treatments such as counselling and CBT can be offered if available. Persistent mild depression should be referred on as for moderate and severe depression.
• Moderate and severe depression: refer to child and adolescent mental health services. Medication and/or specialist psychological care will be needed. If there are immediate concerns about self-harm or suicide risk, refer urgently to tier 3 or 4 services. Otherwise, refer to tier 2 services.

• Psychological treatments
  • Advice – on exercise, diet and sleep hygiene should be offered at tier 1 on initial presentation of mild depression and in those with low mood not meeting the criteria for depression.
  • Self-help – via leaflets, booklets and information. Only offer in the context of appropriate follow-up or a package of care.
  • Counselling/interpersonal therapy may be available within educational settings or by tier 2 CAMHS. Useful in mild depression. Some tier 2 services are able to offer 6-10 sessions as a brief intervention.
  • Cognitive behavioural therapy (CBT) is likely to be beneficial in mild depression and for young people with moderate depression who refuse medication (see www.nice.org.uk/nicemedia/pdf/cg028fullguideline.pdf). Some services are able to offer group CBT which can increase access to treatment for more young people with mild depression. Brief courses of CBT can be provided over 6-12 weeks. CBT may be offered in addition to fluoxetine.
  • Other brief interventions are sometimes provided at tier 2 such as brief family therapy.
  • Interpersonal therapy (IPT) delivered by social workers looks promising for young people with mild to moderate depression; but there are few trained IPT therapists in the UK.
  • Longer-term interventions such as psychotherapy and family therapy are usually offered within tier 3.

• Medication
  • Tricyclic antidepressants are not recommended for young people under the age of 18 years. There is little evidence of their effectiveness, side effects are common and toxicity is a serious concern in overdosage. 
  • Selective serotonin re-uptake inhibitors (SSRIs): fluoxetine is the first-line treatment for moderate and severe depression in adolescence as there is good evidence of its safety and efficacy. It should only be started by a specialist (rather than a GP). There is conflicting guidance about whether any SSRIs other than fluoxetine should be prescribed to adolescents following concerns about safety eg increased risk of suicide, and effectiveness.

Practical tips for the busy GP >>

EGP 1. May 2008