depression

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Assessment 

  1. Diagnosis of major depressive disorder and persistent depressive disorder (previously called dysthymia) is based on clinical judgement, informed by both severity of depressive symptoms (see below for rating scales), functional impairment and diagnostic criteria (DSM-5 or ICD-10). Watch how Dr Mary Emeleus approaches assessment for depression in young people
  2. Consider the context in which the symptoms are presenting. Watch an example of a GP conducting a HEADSS assessment.
  3. With the young person’s consent, multiple informants should be involved. Address confidentiality issues and concerns.
  4. Immediately assess for risk of suicide and involve caregivers, if necessary. Watch an example of a GP asking about suicide and self-harm
  5. Be vigilant for signs of self-harm and assess risk. Watch an example of a GP assessing risk of self-harm
  6. Depression and anxiety are highly co-morbid and symptoms of both can be screened using the DASS (for 18+) or the RCADS (for 13 to 18 years).  RCADS scoring programs (downloadable xls format) are available (scoring is in the second tab).
    1. The longer version has 47 items and is validated to screen for separation anxiety, generalized anxiety, panic, social phobia and obsessive compulsiveness in addition to ‘total’ anxiety and depression scores.
    2. RCADS-25  is a short version that is validated to screen for anxiety and depression.
  7. The PHQ-9 can then be used to further assess depression if indicated by the above screeners
  8. Also consider differential diagnoses and comorbidities. Watch Dr. Sandra Radovini outlining when to consider Bipolar Disorder in young people
  9. Consider the impact of diagnosis on the young person before diagnosing. Watch two young people outlining the impact that receiving a diagnosis had on their life

 

 

Management 

Depression in young people should be treated in a staged manner according to the severity of symptoms and risk. Unless symptoms are severe, CBT/IPT-A are the first line treatments for depression. SSRIs should only be offered as a combined intervention with a psychological therapy, and fluoxetine is the SSRI of choice. The youth-specific beyondblue (2011) Clinical Practice Guidelines for the Identification and Treatment of Depression in Adolescents and Young Adults are now out-of-date. Clinicians are recommended to use the National Institute for Health and Care Excellence (NICE, UK) guideline (NG134) Depression in Children and Young People: Identification and Management. While these guidelines are for adolescents up to the age of 18, it is more appropriate to use these guidelines to inform treatment of young adults (aged 18-25 years) rather than adult guidelines for a number of reasons. For more information see the headspace resource Evidence to Practice Guide: Using SSRI and SNRI Antidepressants to Treat Depression in Young People.

Apply Shared Decision Making where possible.

Guidelines for treating depression in young people (aged 12-25 years – based on NICE CG134)

Persistent depressive mood disorder or mild depression (PHQ 5-9)

  1. Provide psychoinformation to young person and their family members (e.g. depression, 7 tips for a healthy headspace) including lifestyle advice (e.g. sleep, diet, exercise)
  2. Provide psychological therapy if indicated (group CBT, group IPT-A, or online CBT)
  3. Consider the young person’s treatment preferences
  4. Offer individual CBT/IPT-A if group or online therapies are not considered appropriate or do not meet the young person’s preferences

 

Moderate to severe depression (PHQ 10-14)

  1. Refer to specialist service for further assessment and review
  2. Following multi-disciplinary review offer either:
    1. At least 3 months of CBT, IPT-A with review after 4-6 sessions and offer the addition of fluoxetine to psychological therapy (i.e. combined treatment) if unresponsive; or
    2. combined therapy (CBT or IPT-A plus fluoxetine) 
    3. Consider the young person’s treatment preferences

* E-therapies are currently not recommended as first-line treatment for established depressive disorders with moderate or severe symptoms [1-2]. The use of online/computerised CBT can be recommended to young people with mild depressive symptoms and persistent depressive mood disorder. They can also be considered for young people with moderate-to-severe symptoms who cannot access or refuse face-to-face treatment, but after collaborative discussion of evidence-based treatment options with the young person and with appropriate monitoring [3]. To find recommended interventions for young people, clinicians can search depression in HeadtoHealth and filter the search by age-group (12-18; 18-25 years; and by resource type (therapist assisted).

References

[1]. McDermott B, Baigent M, Chanen A et al. Beyond Blue Expert Working Committee 2010 Clinical practice guidelines: Depression in adolescents and young adults. Melbourne: Beyond Blue: the national depression initiative.

[2] NICE (NG134; 2019): Depression in young people: recognition and management.

[3] Bartholomeusz C., Cooke S. & Randell A. (in press): Evidence to Practice Guide: Using SSRI and SNRI Antidepressants to Treat Depression in Young People.

Antidepressant medication and young people

  1. The evidence surrounding of the use of SSRIs and SNRIs in young people, and clinical tips on using SSRIs with young people can be found in Evidence to Practice Guide: Using SSRI and SNRI Antidepressants to Treat Depression in Young People.
  2. Antidepressants should not be used to treat mild depressive disorder or persistent depressive mood disorders.
  3. Medication should not be used as a sole treatment for depression in young people. It should only be used as a combined treatment (i.e. in conjunction with CBT/IPT-A), and if symptoms are moderate-to-severe.  
  4. If CBT/IPT-A is unavailable to the young person (e.g. due to location), online CBT is available from eheadspace and through other online platforms (e.g. Moodgym (aged 16+) teenstrong; mindspot mood mechanic). You can search for suitable therapist-assisted programs on head2health.gov.au (tip – filter your search by age 12-18 years or 18-25 years; and resource type – therapist assisted). GPs should still provide monitoring and psychoeducation in this instance.
  5. If medication is being considered, fluoxetine is the recommended agent to try first
  6. Family and friends should be involved in discussions regarding medication wherever possible
  7. Check off this list before prescribing an SSRI to a young person
  8. Young people (and their caregivers where relevant) should be informed about the potential side effects of medication, including the risk of increased suicidality, self-harm and hostility when commencing medication and the importance of regular reviews (including formal monitoring).
  9. Both the benefits and risks of prescribing an antidepressant should be considered on an individual basis. In circumstances where the young person has moderate to severe depression, and psychological therapy is not possible (for example, poor engagement) or was refused, an antidepressant medication may be considered. Note that, ‘watchful waiting’ (or doing nothing) is not recommended for young people with moderate to severe depression.

 

 

 

Monitoring

  1. Regular monitoring is essential for young people with depression
  2. There are online tools and apps to help young people to monitor their own mood (e.g. myCompass)
  3. If a young person is prescribed medication, you should monitor their mood, suicidal ideation and behaviours, and side effects
  • Unless it seems antidepressants need to be started immediately, symptoms that might be subsequently interpreted as side effects should be monitored for 7 days before prescribing.
  • Monitor within one week of first prescribing, and weekly for the first month
  • Arrange weekly appointments for people assessed to be at risk of suicide until there is no indication of increased suicide risk, then every 2-4 weeks during the first 3 months of treatment and every month thereafter
  • The young person and their family/caregivers (if involved) to monitor for adverse effects relating to deterioration in mood, emergence or exacerbation of self-harm, suicidality, or hostility and seek urgent follow-up if they have any concerns
  1. If you are unable to monitor this regularly, make sure that monitoring is discussed with other staff involved (e.g. psychologist), caregivers, and the young person themselves.

It is strongly encouraged to consult the full NICE clinical guidelines for managing depression in young people for more detailed guidance on prescribing medication. As above, it is recommended to use these guidelines in treating all young people (aged 12-25 years). Clinicians are also encouraged to read headspace’s (2020) Evidence to Practice Guide: Using SSRI and SNRI Antidepressants to Treat Depression in Young People.

 

Continuing Care

  1. Learn about depression and the effective use of treatments from headspace and ReachOut
  2. Monitor mood changes and identify personal early warning signs (e.g. sleep changes, feelings of helplessness).
  3. Identify activities that have a positive impact on mood (e.g. listening to music, visiting friends) and include as routine activities
  4. Ensure that the young person follows the management plan, even when symptoms start to improve – for example ensure that medication is taken for the period advised and psychological therapy sessions are completed as guided in your reviews
  5. Encourage a healthy lifestyle, including exercise, proper nutrition and good sleep habits
  6. Suggest a range of strategies for coping with stress
  7. Encourage contact with friends and family and avoiding spending too much time alone
  8. Encourage the young person to elicit support from their family and friends

 

 

As sleep problems are very common among young people experiencing depression, clinicians may also find headspace’s Evidence to practice resource assessing and responding to sleep problems in young people presenting with mental health difficulties helpful. In addition, Orygen’s Clinical Practice Point: Supporting clinicians to work with parents of young people who self-harm may be helpful.

 

 

For Clients 

Information for mild, moderate and severe depression

 

Information for mild depression only

 

Information for moderate-severe depression only

 

For Family and Friends

 

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