A new review authored by three Canadian psychiatrists aims to help primary care physicians diagnose and manage depression in adolescents.
Depression is common among Canadian teenagers and often goes unnoticed. Many family doctors report feeling unprepared to identify and manage depression in these patients.
“Depression is an increasingly common but treatable condition among adolescents,” the authors wrote. “General practitioners and pediatricians are well positioned to support first-line assessment and management of depression in this group, helping patients regain health and function.”
The article was published on May 29 in CMJ extension.
Distinct presentation
More than 40% of cases of depression begin in childhood. Onset at this stage of life is associated with worse depression severity in adulthood and worse social, occupational, and physical health outcomes.
Depression is influenced by genetic and environmental factors. Family history of depression is associated with a three- to five-fold increased risk of depression among older children. Genetic loci are known to be associated with depression, but parental exposure to depression, adverse childhood experiences, and family conflicts are also linked to increased risk. Bullying and stigma are associated with higher risk among lesbian, gay, bisexual and transgender youth.
Compared with adults, depressed adolescents are more likely to be irritable and have a volatile mood, rather than a depressed mood. Social withdrawal is also more common among adolescents than adults. There may also be unusual features, such as hypersomnia and increased appetite. Anxiety, somatic symptoms, psychomotor agitation, and hallucinations are more common in adolescents than in younger people with depression. Assessing the risk of suicide and self-harm is essential, and support systems and validated scales such as the Columbia Suicide Severity Rating Scale can be helpful.
There is no consensus that universal screening for depression is beneficial among adolescents. “Screening in this age group may be a reasonable approach, however, when implemented in conjunction with adequate systems that ensure accurate diagnosis and appropriate follow-up,” the authors wrote.
Management of depression in adolescents should begin with psychoeducation and can include lifestyle changes, psychotherapy, and medications. “Importantly, a suicide risk assessment should be performed to ensure the adequacy of an outpatient management plan and to facilitate safety planning,” the authors write.
Lifestyle interventions can target physical activity, diet and sleep, as unhealthy patterns in all three are associated with heightened depression symptoms in this population. Regular moderate to vigorous physical activity and perhaps short-term physical activity can improve mood in adolescents. Reduced consumption of sugary drinks, processed foods, and meats, along with increased consumption of fruits and legumes, have been shown to reduce depressive symptoms in randomized controlled trials with adults.
Among psychotherapeutic approaches, cognitive behavioral therapy has shown the greatest evidence of efficacy among adolescents with depression, although it is least effective for those with more severe symptoms, poor coping skills, and nonsuicidal self-harm. Some evidence supports interpersonal therapy, which focuses on relationships and social functioning. Involvement of caregivers may improve response, compared with psychotherapy that includes only the adolescent.
The authors recommend antidepressant medications in severe cases or when psychotherapy is ineffective or impossible. Guidelines generally support trials with at least two selective serotonin reuptake inhibitors before switching to another class of drugs, as efficacy data for them are sparser and other drugs have worse side effect profiles.
About 2% of adolescents with depression experience an increase in suicidal ideation and behavior after exposure to antidepressants, usually within the first few weeks of starting them, so this potential risk should be discussed with patients and healthcare professionals.
Doctors feel unprepared
Commenting on the review for Medscape, Pierre-Paul Tellier, MD, an associate professor of family medicine at McGill University in Montreal, said doctors often report feeling unsure about their ability to manage and diagnose adolescent depression. “We did two systematic reviews to look at the continuing professional development of family doctors in adolescent health, and found that there really is a big gap. When we looked at the residents and the training they were receiving in adolescent medicine, It was very similar, so they felt unprepared to deal with mental health issues.”
The drugs can be effective, but they can be seen as “an easy way out,” Tellier added. “It’s not necessarily an ideal plan. What we need to do is change the way the person thinks, how the person responds to a variety of things that are going to happen throughout their life. People will have other transitional periods in their life. It’s best if they learn a variety of techniques for coping with depression.”
These techniques include exercise, relaxation methods (which reduce anxiety), and wellness training. Through such techniques, patients “learn a healthier way to live with themselves and who they are, and so that’s a lifelong learning,” Tellier said. “If I give you a pill, what I’m teaching is, yes, you can feel better. But you’re not dealing with the problem, you’re just dealing with the symptoms.”
He often directs his patients to YouTube videos outlining and explaining various strategies. One of his favorites is a deep breathing exercise presented by Jeremy Howick.
The authors and Tellier disclosed no relevant financial relationships
CMJ extension. May 29, 2023. Full text
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