Depression assessment and treatment

About

People with depressive disorders have persistently depressed mood or loss of interest or pleasure in usual activities, often accompanied by changes in thinking, behaviour and/or physical health. Having depression is also a significant risk factor for suicidal thoughts or actions.

The typical symptoms of major depression in a young person include:

Emotional changes:

• Feelings of unhappiness, or moodiness and irritability, and sometimes emptiness or numbness
• Tearfulness or frequent crying
• Feelings of worthlessness and guilt, sadness and/or hopelessness
• Losing interest and pleasure in activities that was once enjoyed
• Tiredness, lack of energy and motivation
• Feeling worried or tense
  
  

Cognitive changes:

• Difficulty concentrating and making decisions
• Being self-critical and self-blaming
• Negative body image and low self esteem
• Having dark and gloomy thoughts, including thoughts of death or suicide
  
  

Behavioural changes:

• Poor attention to personal hygiene and appearance
• Decreased participation with peers and normally enjoyed activities
• Self harm or deteriorated self-care
• Avoidance of family interactions and activities
• More withdrawn behaviour, including clearly more time spent alone
  
  

Physical changes:

• Loss of appetite and weight (but sometimes people 'comfort eat' and put on weight)
• Either difficulty sleeping, or over-sleeping and staying in bed most of the day
• Lowered libido
• Restlessness and agitation, or being slowed down
• Unexplained aches and pains
  
  

Onset, prevalence, and burden of depression in young people

Depressive disorders tend to first appear in adolescence or early adulthood. Overall, about 25% of people who develop a depressive disorder will do so before the age of 20 years, and 50% before the age of 30 years (1).

Depression is the most frequently managed mental health problem for young people aged 12-24 years, with 13.5% of GP encounters for mental health reasons in Australia related to this disorder (3).

The lifetime prevalence of depression is 16.6% and the rates tend to be higher among young females compared to young males. In a single year, 3 in 100 Australian males aged 18-24 years, and 1 in 10 females of the same age will have a depressive disorder (1,2).

Depression is the leading contributor to the burden of disease and injury in females aged 10-24 years, and the second leading contributor (after road traffic accidents) for males of the same age (4).

A number of factors are known to increase the likelihood that a person will experience a depressive disorder (5-7). They include:

• Genetic vulnerability (heritability of depression during adolescence is estimated at 30-50%, and having a parent with depression increases a person's risk of also developing depression by 3-4 times (6))
• Stressful life events (more associated with females and those with an underlying genetic vulnerability)
• Chronic relationship stressors or interpersonal difficulties
• Family adversity (e.g. negative family relationships)
• Peer victimization and bullying
• Unhelpful thinking styles that contribute to low self-esteem and high self-criticism, a sense of low self-efficacy, and a sense of helplessness and hopelessness
  
  

Having a genetic vulnerability or being exposed to adversity does not mean a young person will develop a depressive disorder. Research on resilience has found a number of protective factors that can reduce a young person's risk of developing depression. The most consistent finding is related to having good quality interpersonal relationships (e.g. the presence of a supportive adult). Other protective factors include having adaptive coping mechanisms and thinking styles, and parental relationships that are characterized by warmth and acceptance, and low hostility and parental control (5,8).

Depression and other mental health problems

Depression is often associated with other mental illnesses, and it is estimated that two-thirds of young people with depression have at least one comorbid mental disorder (5). Compared to young people who are not depressed, young people with depression are 6-12 times more likely to have anxiety, 4-11 times more likely to have a disruptive behavior disorder (e.g. conduct disorder, ADHD), and 3-6 times more likely to have substance misuse problems (9). Depressive disorders in young people are also a major risk factor for suicide (5, 10).

References

1. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.

2. Australian Institute of Health and Welfare 2011. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140 Canberra: AIHW

3. Australian Institute of Health and Welfare 2007. Young Australians: their health and wellbeing 2007. Cat. no. PHE 87 Canberra: AIHW.

4. Gore, F. M., Bloem, P. J., Patton, G. C., Ferguson, J., Joseph, V., Coffey, C., ... & Mathers, C. D. (2011). Global burden of disease in young people aged 10-24 years: a systematic analysis. The Lancet, 377(9783), 2093-2102.

5. Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. The Lancet, 379(9820), 1056-1067.

6. Rice, F., Harold, G., & Thapar, A. (2002). The genetic aetiology of childhood depression: a review. Journal of Child Psychology and Psychiatry, 43(1), 65-79.

7. Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., ... & Nelson, B. (1996). Childhood and adolescent depression: a review of the past 10 years. Part I. Journal of the American Academy of Child & Adolescent Psychiatry, 35(11), 1427-1439.

8. Reivich, K., Gillham, J. E., Chaplin, T. M., & Seligman, M. E. (2013). From helplessness to optimism: The role of resilience in treating and preventing depression in youth. In Handbook of Resilience in Children (pp. 201-214). Springer US.

9. Costello, E. J., Foley, D. L., & Angold, A. (2006). 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II. Developmental epidemiology. Journal of the American Academy of Child & Adolescent Psychiatry, 45(1), 8-25.

10. Cash, S. J., & Bridge, J. A. (2009). Epidemiology of youth suicide and suicidal behavior. Current Opinion in Pediatrics, 21(5), 613.

Assessment

Formal systems for the diagnosis of mental illness (1,2) describe a number of different types of depressive disorder, including:

• Major depressive disorder
• Persistent depressive disorder (dysthymia)
• Recurrent or persistent depression with mild, moderate or severe episodes
• Severe depression with psychotic symptoms
• Premenstrual dysphoric disorder
• Substance-induced depressive disorder
  
  

Assessment tools

To decide whether a young person may be experiencing depression, an assessment is required.  A comprehensive assessment involves asking questions about a range of aspects of the young person's life including their:

• Home and environment;
• Education and employment;
• Activities;
• Drugs and alcohol;
• Relationships and sexuality;
• Conduct difficulties and risk-taking;
• Anxiety and eating;
• Depression symptoms and suicide risk;
• Psychosis and mania symptoms
  
  

For more information, see the headspace psychosocial assessment interview

There are several assessment tools available to assess or screen for depressive disorders. These include the Beck's Depression Inventory (BDI) (3), the Depression Anxiety Stress Scales (4), and the Hamilton Depression Rating Scale (HDRS) (5). These questionnaires are not a diagnostic tool but rather to assist with identifying when a more detailed assessment is warranted.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

2. Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77-100.

3. Lovibond, S.H. & Lovibond, P.F. (1995).  Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) Sydney: Psychology Foundation.  ISBN 7334-1423-0.

4. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23(1), 56.

5. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization

Treatment

Young people with depression often have co-occurring symptoms related to other mental disorders (e.g. anxiety). This can increase the difficulty of making an early and accurate diagnosis.
Because of the high personal costs of depression, including an increased risk of suicide, it is essential that young people receive effective treatment. At the very least, this should include assessment and engagement in a supportive relationship with a health professional.

The management plan developed for a young person with depression will be dependent upon a range of factors including:

• Severity of symptoms
• Health services available, both in terms of actual services to refer to and the skills and experiences of workers involved
• Other presenting health issues
• Support network available, including family or friends, school supports
• The young person's preferences for a particular type of treatment
  
  

The foundation for any helping relationship is establishing a therapeutic alliance, openly discussing the problem, and having a collaborative approach.  Helpful strategies that can be introduced within this helping relationship include skill development around problem solving, stress management and activity planning.

For young people with mild depression, there is good evidence for the effectiveness cognitive behavioural therapy (1,2). Simple interventions that might also be effective in the treatment of mild depression include exercise (3) and some alternative and complementary interventions, such as relaxation therapy and omega-3 fatty acid supplements (4).

More targeted treatment will be needed when depression is moderate-severe, and this might involve specialist (adolescent mental health services) clinical care (1). While there is some evidence for the effectiveness of interpersonal therapy (5,6), cognitive behavioural therapy (CBT) is the most researched psychological treatment for depression. More recent systematic reviews (5-8) have found moderate but significant effect sizes in the short-term for the use of group or individual cognitive behavior therapy (4,5) with young people with moderate-severe depression.

Medication may be necessary in some cases. Systematic reviews suggest than tricyclic drugs are not useful in treating depression in young people (9), while fluoxetine might be the first choice if medication is decided upon (10). It is important to consider that there is evidence of an increased risk of suicidal ideation and behaviour in those treated with antidepressant medication, and this needs to be balanced with the potential risks (e.g. suicide and impact on functioning) associated with untreated depression.

Two large-scale trials have investigated the effectiveness of the combined use of CBT and antidepressant medication in young people with a depressive disorder, and results were conflicting. The Treatment for Adolescents With Depression Study (TADS) found that the combination of fluoxetine and CBT was significantly better than either alone in the short-term (11). However, the Adolescent Depression Antidepressant and Psychotherapy (ADAPT) study found that the addition of CBT to fluoxetine plus standard care did not appear to improve outcomes compared to fluoxetine plus standard care (12).  A systematic review (13) of the use of psychological therapies versus antidepressant medication (alone or in combination) for depression in young people pooled findings from 11 studies, and overall was unable to make conclusions of effectiveness due to conflicting results.

There is good evidence that targeted and universal depression prevention programs may prevent the onset of depressive disorders compared with no intervention (14,15). Overall, most of the programs have used elements of CBT or interpersonal therapy.

References

1. Thapar, A., Collishaw, S., Potter, R., & Thapar, A. K. (2010). Managing and preventing depression in adolescents. BMJ, 340.

2. Calear, A. L., & Christensen, H. (2010). Systematic review of school-based prevention and early intervention programs for depression. Journal of Adolescence, 33(3), 429-438.

3. Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004691. DOI: 10.1002/14651858.CD004691.pub2.

4. Jorm, A. F., Allen, N. B., O Donnell, C. P., Parslow, R. A., Purcell, R., & Morgan, A. J. (2006). Effectiveness of complementary and self-help treatments for depression in children and adolescents. Medical Journal of Australia, 185(7), 368.

5. Watanabe, N., Hunot, V., Omori, I. M., Churchill, R., & Furukawa, T. A. (2007). Psychotherapy for depression among children and adolescents: a systematic review. Acta Psychiatrica Scandinavica, 116(2), 84-95.

6. David-Ferdon, C., & Kaslow, N. J. (2008). Evidence-based psychosocial treatments for child and adolescent depression. Journal of Clinical Child & Adolescent Psychology, 37(1), 62-104.

7. Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006). Effects of psychotherapy for depression in children and adolescents: a meta-analysis. Psychological Bulletin, 132(1), 132.

8. Klein, J. B., Jacobs, R. H., & Reinecke, M. A. (2007). Cognitive-behavioral therapy for adolescent depression: a meta-analytic investigation of changes in effect-size estimates. Journal of the American Academy of Child & Adolescent Psychiatry, 46(11), 1403-1413.

9. Hazell P, Mirzaie M. Tricyclic drugs for depression in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD002317. DOI: 10.1002/14651858.CD002317.pub2.

10. Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN. Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD004851.           DOI: 10.1002/14651858.CD004851.pub3.

11. March, J., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., ... & Severe, J. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA, 292(7), 807-820.

12. Goodyer, I., Dubicka, B., Wilkinson, P., Kelvin, R., Roberts, C., Byford, S., ... & Harrington, R. (2007). Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. BMJ, 335(7611), 142.

13. Cox GR, Callahan P, Churchill R, Hunot V, Merry SN, Parker AG, Hetrick SE. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD008324. DOI: 10.1002/14651858.CD008324.pub3.

14. Gladstone, T. R. (2009). The Prevention of Depression in Children and Adolescents: A Review. Canadian Journal Of Psychiatry, 54(4), 212-221.

15. Merry SN, Hetrick SE, Cox GR, Brudevold-Iversen T, Bir JJ, McDowell H. Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD003380. DOI: 10.1002/14651858.CD003380.pub3.

Guidelines

The following authoritative guidelines provide evidence-based information about the practical treatment of depressive disorders:

Depression in children and young people: Identification and management in primary, community and secondary care (2015). National Institute of Health and Clinical Excellence (NICE) CG28. United Kingdom

Depression in children and young people (2013). National Institute of Health and Clinical Excellence (NICE) QS48. United Kingdom

Clinical Practice Guidelines: Depression in Adolescents and Young Adults (2011) Beyond Blue: the national depression initiative

Clinical guidance on the use of antidepressant medications in children and adolescents (2005). Royal Australian and New Zealand College of Psychiatrists

Australian and New Zealand clinical practice guidelines for the treatment of depression (2004) Royal Australian and New Zealand College of Psychiatrists

More Information

The following selected articles provide more information about depression:

Centre of Excellence in Youth Mental Health. Evidence Summary: Using SSRI Antidepressants and Other Newer Antidepressants to Treat Depression in Young People: What are the issues and what is the evidence? (2013). Melbourne: Orygen Youth Health Research Centre.

Cox GR, Fisher CA, De Silva S, Phelan M, Akinwale OP, Simmons MB, Hetrick SE. Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD007504. DOI: 10.1002/14651858.CD007504.pub2.

Stice, E., Shaw, H., Bohon, C., Marti, C. N., & Rohde, P. (2009). A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects. Journal of Consulting and Clinical Psychology, 77(3), 486.

Abela, J. R., & Hankin, B. L. (Eds.). (2008). Handbook of depression in children and adolescents. Guilford Press.

Silk, J. S., Vanderbilt-Adriance, E., Shaw, D. S., Forbes, E. E., Whalen, D. J., Ryan, N. D., & Dahl, R. E. (2007). Resilience among children and adolescents at risk for depression: Mediation and moderation across social and neurobiological contexts. Development and Psychopathology, 19(03), 841-865.

Antidepressant Use in Children, Adolescents, and Adults. (2007). U.S. Food and Drug Administration.

Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. National Institute of Mental Health.