Depression

• 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, moodiness and irritability, and sometimes emptiness or numbness
    • Tearfulness or frequent crying
    • Feelings of worthlessness and guilt, sadness and/or hopeless
    • Losing interest and pleasure in activities that you 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.
  • Behavioral changes:
    • Poor attention to personal hygiene and appearance
    • Decreased participation with peers and normally enjoyed activities
    • Self harm or deteriorated self-care or promiscuity
    • 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    • More withdrawn behaviour including clearly more time spent alone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 trouble sleeping, or over-sleeping and staying in bed most of the day
    • Lowered libido
    • Restlessness and agitation
    • Unexplained aches and pains

  Onset of depression in young people

  Depressive disorders tend to first appear in adolescence or early adulthood (1,2). One in every five adolescents are likely to experience a diagnosable depressive episode by the age of 18 (3,4). In Australia, it's estimated that 6 to 7 percent of young people aged 16 to 24 will experience depression in any year. The rates tend to be higher among young females (8.4%) compared to young males (4.3%)(5).
  
  A number of factors are known to increase the likelihood that a person will experience a depressive disorder. They include:

  • Genetic vulnerability (for example, depressive disorders in other family members)(6), especially in females (7).
  • Stressful life events, especially family adversity (8) and interpersonal difficulties. These stressors seem to be more important in the development of the first episode of depression than in subsequent episodes (9), and in people with a genetic vulnerability (7, 10-11).
  • Low self-esteem, a sense of low self-efficacy, and a sense of helplessness and hopelessness (12).
  • Fluctuating mood, or 'ups and downs', in the past (13).

  Protective factors that can reduce the risk that a young person will develop depression include the presence of a supportive adult, good interpersonal relationships, a strong sense of self (14), family cohesion and social support (15).

  Depression and other mental health problems

  Depression is often associated with other mental illnesses, such as anxiety disorders, disruptive behaviour disorders and substance use disorders (3, 16-17).

  Depressive disorders are the most common identifiable risk factor for suicide (18-22).

   

  References:

  1.Kessler, RC, Berglund, P, et al. Lifetime prevalence and age-of-onset distributions of dsm-iv disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005 Jun;62(6):593-602.

  2.Rutter, M. Relationships between mental disorders in childhood and adulthood. Acta Psychiatr Scand. 1995 Feb;91(2):73-85.

  3.Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J, Dahl RE, Perel J, Nelson B. Childhood and adolescent depression: a review of the past 10 years.Part I. J Am Acad Child Adolesc Psychiatry. 1996 Nov;35(11):1427-39.

  4.Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews JA. Adolescentpsychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abnorm Psychol. 1993 Feb;102(1):133-44.

  5.Australian bureau of statistics. 2007 national survey of mental health and wellbeing: Summary of results. (document 4326.0). 2008

  6. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: review and meta-analysis. Am J Psychiatry. 2000 Oct;157(10):1552-62. 
  
  7. Goldberg D. The aetiology of depression. Psychol Med. 2006 Oct;36(10):1341-7.

  8. Fergusson DM, Lynskey MT. Adolescent resiliency to family adversity. J Child Psychol Psychiatry. 1996 Mar;37(3):281-92

  9. Lewinsohn PM, Allen NB, Seeley JR, Gotlib IH. First onset versus recurrence of depression: differential processes of psychosocial risk. J Abnorm Psychol. 1999 Aug;108(3):483-9.

  10. Kendler KS. Twin studies of psychiatric illness. Current status and future directions. Arch Gen Psychiatry. 1993 Nov;50(11):905-15.

  11. Kendler KS, Kessler RC, Walters EE, MacLean C, Neale MC, Heath AC, Eaves LJ. Stressful life events, genetic liability, and onset of an episode of major depression in women. Am J Psychiatry. 1995 Jun;152(6):833-42.

  12. Asarnow JR, Carlson GA, Guthrie D. Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal
  children. J Consult Clin Psychol. 1987 Jun;55(3):361-6.

  13. Angst J, Gamma A, Endrass J. Risk factors for the bipolar and depression spectra. Acta Psychiatr Scand Suppl. 2003;(418):15-9.

  14. Beardslee WR, Podorefsky D. Resilient adolescents whose parents have serious affective and other psychiatric disorders: importance of self-understanding and relationships. Am J Psychiatry. 1988 Jan;145(1):63-9.

  15. Carbonell, D. M., Reinherz, H. Z., & Giaconia, R. M. (1998). Risk and resilience in late adolescence. Child and Adolescent Social Work Journal, 15, 251-272.

  16. Kovacs M. Presentation and course of major depressive disorder during childhood and later years of the life span. J Am Acad Child Adolesc Psychiatry.1996 Jun;35(6):705-15.

  17. Kovacs M, Gatsonis C, Paulauskas SL, Richards C. Depressive disorders in childhood. IV. A longitudinal study of comorbidity with and risk for anxiety disorders. Arch Gen Psychiatry. 1989 Sep;46(9):776-82.

  18. Lewinsohn, PM, Gotlib, IH, et al. Gender differences in anxiety disorders and anxiety symptoms in adolescents. J Abnorm Psychol. 1998 Feb;107(1):109-17.

  19. Spirito A, Esposito-Smythers C. Attempted and completed suicide in adolescence. Annu Rev Clin Psychol. 2006;2:237-66.

  20. Sanchez LE, Le LT. Suicide in mood disorders. Depress Anxiety.
  2001;14(3):177-82.

  21. Esposito, CL, Clum, GA. Psychiatric symptoms and their relationship to suicidal ideation in a high-risk adolescent community sample. J Am Acad Child Adolesc Psychiatry. 2002 Jan;41(1):44-51.

  22. Brent DA, Kalas R, Edelbrock C, Costello AJ, Dulcan MK, Conover N. Psychopathology and its relationship to suicidal ideation in childhood and adolescence. J Am Acad Child Psychiatry.
• Assessment

  Formal systems for the diagnosis of mental illness (DSM-IV criteria for relevant mood disorders) (ICD-10 codes for relevant mood disorders) (DSM-IV appendix) define a number of different types of depressive disorder, including:

  • major depressive disorder
  • dysthymic disorder
  • recurrent or persistent depression with mild, moderate or severe episodes
  • minor depressive disorder
  • recurrent brief depression
  • mixed anxious depressive disorder.

  It is now known that mild depressive disorders increase the chance of developing more severe depression (1-4) and can result in increased risk of mortality comparable to that seen with more severe presentations (5).

  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 assessment

  References:

  1. Wilcox HC, Anthony JC. Child and adolescent clinical features as forerunners of adult-onset major depressive disorder: retrospective evidence from an epidemiological sample. J Affect Disord. 2004 Oct 1;82(1):9-20.

  2. Cuijpers, P, Smit, F. Subthreshold depression as a risk indicator for major depressive disorder: A systematic review of prospective studies. Acta Psychiatr Scand. 2004 May;109(5):325-31.

  3. Cuijpers, P, Smit, F, et al. Predicting the onset of major depression in subjects with subthreshold depression in primary care: A prospective study. Acta Psychiatr Scand. 2005 Feb;111(2):133-8.

  4. Fergusson, DM, Horwood, LJ, et al. Subthreshold depression in adolescence and mental health outcomes in adulthood. Arch Gen Psychiatry. 2005 Jan;62(1):66-72.

  5. Cuijpers, P, Smit, F. Excess mortality in depression: A meta-analysis of community studies. J Affect Disord. 2002 Dec;72(3):227-36.

• Treatment

  Young people with depression often have symptoms of anxiety, and sometimes, physical illness (1,2). 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:

  • the severity of symptoms
  • the 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 persons' 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.  Other helpful strategies that can be introduced within this helping relationship include skill development around problem solving, stress management and activity planning. Other simple interventions that might be effective in young people with mild depression include exercise (3), some alternative and complementary interventions such as relaxation therapy and omega-3 fatty acid supplements (4), and psychoeducation (5).
  
  More targeted treatment will be needed when depression is more severe. There is strong evidence for the effectiveness of talking therapies for young people with depression such as Cognitive Behaviour Therapy (CBT) (6) and Interpersonal Psychotherapy (IPT) (7). Medication may be necessary in some cases. Fluoxetine may be effective for some, but not all, young people (8). However the risks of antidepressant treatment, including a possible increase in the risk of suicidal ideation and suicidal behaviour, must also be considered (8).

  The evidence map provides reference details for studies of prevention and treatment interventions for depression in young people

   

  References
  1. Axelson DA, Birmaher B. Relation between anxiety and depressive disorders in childhood and adolescence. Depress Anxiety. 2001;14(2):67-78.

  2. Rivas-Vazquez, RA, Saffa-Biller D, Ruiz I, Blais MA, Rivas-Vasquez, A.  Current Issues in Anxiety and Depression: Comorbid, Mixed, and Subthreshold Disorders. Prof Psychol Res Pr. 2004; 35(1):74 - 83

  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 Syst Rev. 2006 Jul 19;3:CD004691.

  4. Jorm AF, Allen NB, O'Donnell CP, Parslow RA, Purcell R, Morgan AJ. Effectiveness of complementary and self-help treatments for depression in children and adolescents. Med J Aust. 2006 Oct 2;185(7):368-72.

  5. Dowrick C, Dunn G, Ayuso-Mateos JL, Dalgard OS, et al Problem solving treatment and group psychoeducation for depression: multicentre randomised controlled trial. Outcomes of Depression International Network (ODIN) Group. BMJ. 2000; 321 (7274):1450-4.

  6. Harrington R, Campbell F, Shoebridge P, Whittaker J. Meta-analysis of CBT for depression in adolescents. J Am Acad Child Adolesc Psychiatry. 1998 Oct;37(10):1005-7.

  7. Brunstein-Klomek, A, Zalsman, G, et al. Interpersonal psychotherapy for depressed adolescents. Isr J Psychiatry Relat Sci. 2007;44(1):40-6.

  8. Hetrick S, Merry S, McKenzie J, Sindahl P, Proctor M. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004851.

• Guidelines

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

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

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

  Identification of common mental disorders and management of depression in primary care. (2008) New Zealand Guidelines Group

  Depression in children and young people: identification and management in primary, community and secondary care (2005) National Institute of Health and Clinical Excellence (NICE) CG28. United Kingdom

  Depression: the treatment and management of depression in adults (2009) National Institute of Health and Clinical Excellence (NICE) CG90. United Kingdom

  Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. (2007) Zuckerbrot et al, Pediatrics Vol. 120 No. 5 November 2007, pp. e1299-e1312 Endorsed by the American Academy of Pediatrics. United States of America

  Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. (2008) Cheung et al, Pediatrics Vol. 120 No. 5 November 2007, pp. e1313-e1326 Endorsed by the American Academy of Pediatrics. United States of America

  Practice parameters for the assessment and treatment of children and adolescents with depressive disorders (2007) American Academy of Child and Adolescent Psychiatry

  Screening and treatment for major depressive disorder in children and adolescents (2009) : U.S. Preventive Services Task Force recommendation statement. United States of America

  Practice guideline for the treatment of patients with major depressive disorder, third edition. (2010). American Psychiatric Association.  United States of America

• More info

  The following selected articles and web sites provide more information about anxiety disorders and anxiety intervention research:

  Lewinsohn, PM, Rohde, P, et al. Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clin Psychol Rev. 1998 Nov;18(7):765-94.

  Fergusson, DM, Boden, JM, et al. Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes. Br J Psychiatry. 2007 Oct;191:335-42.

  Ebmeier, KP, Donaghey, C, et al. Recent developments and current controversies in depression. Lancet. 2006 Jan 14;367(9505):153-67.

  Ryan, ND. Treatment of depression in children and adolescents. Lancet. 2005 Sep 10-16;366(9489):933-40.

  Goodman W, Murphy T, Storch E. Risk of adverse behavioral effects with pediatric use of antidepressants. Psychopharmacology. 2007;191(1):87-96.

  Garber, J. Depression in children and adolescents: Linking risk research and prevention. Am J Prev Med. 2006 Dec;31(6 Suppl 1):S104-25.

  Gladstone TRG, Beardslee WR. The prevention of depression in at-risk adolescents: Current and future directions. Journal of Cognitive Psychotherapy: An International Quarterly. 2000;14(1):9-23.

  Stice E, Shaw H, Bohon C, Marti CN, Rohde P. A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects. J Consult Clin Psychol. 2009 Jun;77(3):486-503. PubMed PMID: 19485590;

  Hamrin V, Pachler MC. Child & adolescent depression: review of the latest evidence-based treatments. Journal of Psychosocial Nursing & Mental Health Services. 2005 Jan;43(1):54-63.