by Maurice Blackman, MB, FRCPC.
Clinical professor and director, division of child and adolescent
University of Alberta Hospitals, Edmonton, Alberta.
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
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
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
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
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
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
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
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
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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