"Teenage Problems"
Adolescent Depression
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 majority of teenage depressions can
be managed successfully by the primary care physician with the support of the
family, 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 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. Lack
of motivation and lowered energy level is reflected by missed classes. 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 psychologic 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. Comorbidity 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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References
1. Murphy, JM, Monson, RR, Olivier, DC, et al: Affective disorders and mortality: A
general population study. Arch Gen Psychiatry 44:470, 1987. 2. Hodgma, CH,
McAnarny, ER: Adolescent depression and suicide: Rising problems. Hosp Pract
127(4):73,1992. 3. Kovaks, M: Affective disorders in children and adolescents. Am J
Psychol 44(2):209,1989 and mentalhealth.com
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