By Dr. Maurice Blackman, MA, MB, BCh, FRCPC
The Canadian Journal of CME May 1995
The suicide rate for adolescents has increased more than 200% over the last decade. Recent studies have shown that greater than 20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics suffer from depression. The primary care physician with the support of the family can manage the majority of teenage depressions successfully, says Maurice Blackman MB, FRCPC.
Depression has been considered to be the major psychiatric disease of the 20th century, affecting approximately eight million people in North America. Adults with psychiatric illness are 20 times more likely to die from accidents or suicide than adults without psychiatric disorder. Major depression, including bipolar affective disorder, often appears for the first time during the teenage years, and early recognition of these conditions will have profound effects on later morbidity and mortality.
Is depression in adolescents a significant problem?
The suicide rate for adolescents has increased more than 200% over the last decade. Adolescent suicide is now responsible for more deaths in youths aged 15 to 19 than cardiovascular disease or cancer. Recent studies have shown that greater than 20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics suffer from depression. Despite this, depression in this age group is greatly underdiagnosed, leading to serious difficulties in school, work and personal adjustment, which often continue, into adulthood.
Why is depression in this age group often missed?
Adolescence is a time of emotional turmoil, mood lability, gloomy introspection, great drama and heightened sensitivity. It is a time of rebellion and behavioral experimentation. The physician's challenge is to identify depressive symptomatology, which may be superimposed on the backdrop of a more transient, but expected, developmental storm.
Diagnosis, therefore, must rely not only on a formal clinical interview but also on information provided by collaterals, including parents, teachers and community advisors. The patient's premorbid personality must be taken into account, as well as any obvious or subtle stress or trauma that may have preceded the clinical state. The therapeutic alliance is very important since the adolescent will not usually readily share his/her feelings with an adult stranger unless trust and rapport are established.
Confidentiality must be assured, but not to the point that the parents - who are often essential allies in treatment - are wholly excluded. Diagnosis may require more than one interview and is not a process that can be rushed. Inquire directly about possible suicidal ideation.
What are the common symptoms of adolescent depression?Depression presents in adolescents with essentially the same symptoms as in adults; however, some clinical shrewdness may be required to translate the teenagers' symptoms into adult terms. Pervasive sadness may be exemplified by wearing black clothes, writing poetry with morbid themes or a preoccupation with music that has nihilistic themes. Sleep disturbance may manifest as all-night television watching, difficulty in getting up for school, or sleeping during the day. Missed classes reflect lack of motivation and lowered energy level. A drop in grade averages can be equated with loss of concentration and slowed thinking. Boredom may be a synonym for feeling depressed. Loss of appetite may become anorexia or bulimia. Adolescent depression may also present primarily as a behavior or conduct disorder, substance or alcohol abuse or as family turmoil and rebellion with no obvious symptoms reminiscent of depression.
Formal psychological testing may be helpful in complicated presentations that do not lend themselves easily to diagnosis. In the most difficult cases, a trial of treatment may be required to differentiate clinical depression from extreme developmental turmoil or conduct disorders.
How can suicide risk be determined?
It is not uncommon for young people to be preoccupied with issues of mortality and to contemplate the effect their death would have on close family and friends. Thankfully, these ideas are usually not acted upon. Suicidal acts are generally associated with a significant acute crisis in the teenager's life and may also involve concomitant depression. It is important to stress that the crisis may be insignificant to the adults around, but very significant to the teenager. The loss of a boyfriend or girlfriend, a drop in school marks or a negative admonition by a significant adult, especially a parent or teacher, may be precipitant to a suicidal act. Suicidal ideation and acts are more common among children who have already experienced significant stress in their lives.
Significant stressors include divorce, parent or family discord, physical or sexual abuse and alcohol or substance abuse. A suicide in a relative or close friend may also be an important identifier of those at the greatest risk. The teenager who exhibits obvious personality change, including social withdrawal, or who gives away treasured possessions may also be seriously contemplating ending his/her life.
Many more teenagers attempt suicide than actually succeed, and the methods used may be naive. There is a tendency to treat perceived minor attempts as attention seeking, histrionic and of no importance. This is a mistake, as a teenager who has attempted suicide and has not received any relief from his or her impossible situation may well be a successful repeater. All suicidal behaviors reflect a cry for help and must be taken seriously.
How can the physician best manage the patient?
The management of the depressed teenager begins at the first interview with the creation of a therapeutic alliance. It is important that the interview be conducted in a relaxed manner, preferably in a room other than a formal examination room. The teenager may have to be brought back the next day or on a number of successive days to adequately address problems. The physician must inspire confidence and trust, and be aware of his or her own biases. Teenagers can be oppositional and negative when depressed. They may have very fragile self-esteem and project their feelings onto the physician. It is important to understand this behavior as part of the depression and treat it accordingly.
Interviews should be conducted with and without the parent(s) present. The rules of confidentiality must be discussed with a clear understanding of which issues will be withheld (e.g., suicide intention). The teenager is an active participant in the treatment process and the physician must identify the problem to the patient and parent, offer hope and reassurance, outline treatment options and arrive at a mutually agreed-upon treatment plan. A family assessment should be undertaken to evaluate what support may be available from family members and what resources are available in crisis.
How should depression in adolescents be treated?
There are two main avenues to treatment: psychotherapy and medication. Often, both may be required. The majority of mild depressions in teenagers respond to supportive psychotherapy with active listening, advice and encouragement. Issues of alcohol and substance abuse may have to be addressed by referral to relevant agencies. Formal family therapy may be required to deal with specific problems or issues. Co morbidity is not unusual in teenagers, and possible pathology, including anxiety, obsessive-compulsive disorder, learning disability or attention deficit hyperactive disorder, should be searched for and treated, if present.
When should medication be used?
For the more serious and persistent depressions, particularly those with vegetative symptoms or suicidal ideation, medication is essential and may be life-saving. Traditional antidepressant drugs generally are poorly tolerated by teenagers because of the common side effects, including sedation and anticholinergic action. This leads to poor compliance. The advent of selective serotonin reuptake inhibitors (SSRIs) has largely put these worries to rest. SSRIs are well tolerated by teenagers because of their fairly rapid action and low tendency to cause side effects. Low toxicity also makes them particularly helpful in an impulsive patient population. It is important that an adequate time period be given to allow the medication to work (four to six weeks) and that adequate doses are used.
There are sufficient choices of SSRIs so that a suitable medication can be found for most symptom clusters. Most teenagers can tolerate adult dosages, and lack of response may reflect a problem with dosage rather than the choice of medication. Some attempt to explain the action of the medication should be given to the patient and family, as should an explanation of possible side effects. Anxiolytic and sleep medication may also be required.
When should the patient be referred to a psychiatrist specializing in adolescents?
Referral should be considered under a number of circumstances. If the physician cannot engage in conversation with the teenager because of the patient's resistance or the physician's own insecurity about dealing with this age group, then referral is suggested. This is particularly important if the depression is judged to be severe or if there have been some suicidal concerns. Referral should also be considered if the patient's condition does not improve in the expected time or if there is any deterioration or worsening of the depression despite adequate treatment. It should be stressed that the majority of teenage depressions can be managed successfully by the primary care physician with the support of the family.
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