Stuart Gill-Banham, BSc (Hons), PGDipPsychPharm
Clinical Lecturer, Medway School of Pharmacy, University of Kent and Greenwich, UK
As in adults, depression in young people is a syndrome that is characterised by low mood, lack of energy and a loss of interest in everyday activities.1 Differences in the presentation of depression between young people and adults, and indeed between children and adolescents, stem from differences in individual development and the ability to express emotional feelings. Often this means, rather than verbalising feelings of depression, young people might exhibit any of the following: irritability, low frustration tolerance, temper tantrums, somatic complaints (vague aches and pains), school avoidance or social withdrawal. Typically, young depressed individuals will have poor self-esteem, with little to say when asked about their good points. This may result in blaming themselves for personal difficulties or significant life events that might have occurred.
The terms ‘child’, ‘adolescent’ and ‘young person’ have been loosely defined. A child is aged between six and 11 years; an adolescent is aged from 12 to 16 years (extending to up to 18 years if remaining in full-time education); and a young person is anyone under the age of 18 years. These definitions are not absolute, as some variation exists and individual development may alter the term that is most appropriate in any given case. However, they offer a rough guide.
Presentation and prevalence of depression in young people
Presentation of depression in young people can vary considerably between individuals, even between those of a similar age.2 Factors such as the severity of illness, personal impairment and developmental age (a measure of a child’s development in terms of body size, motor skills or psychological function) can have a significant influence. In children, somatic features will tend to predominate, which is reflected in numerous complaints of non-specific aches and pains. In adolescents, increasing cognitive features are displayed, reflected in terms of feeling worthless, being self-critical and having poor attention.
It is estimated that 40–90% of young people with a depressive disorder will have at least one other psychiatric diagnosis, and up to 50% will have two or more.3 Differences in diagnostic criteria and difficulty in making diagnoses account for the wide range of prevalence figures from different studies. The most frequent comorbid diagnoses are: anxiety disorders, disruptive disorders, attention deficit hyperactivity disorder (ADHD) and substance abuse disorders (in adolescents).
Course and prognosis
The course of depression and its prognosis in young people is similar to that seen in depression in later life. Around one in ten young people with depression will spontaneously recover within three months. Without intervention, a further 40% will have recovered within one year, but this leaves 50% who will still be struggling with depressive symptoms for a year or more if no intervention is made.1 Although the precise influence that treatment has on prognosis is not clear, the consequences of untreated depression during childhood or adolescence are grave. In the immediate period, the most serious potential consequence is the risk of suicide; estimates are of a 3% risk over the subsequent 10 years.1 Additional consequences of depression in the young centre on school and social functioning. Depression can have a big impact on school performance and the ability to make or maintain friendships. It has been suggested that persistent depressive episodes may lead to altered brain function – described as chemical and psychological scarring – although studies have failed to find this to be more significant than other risk factors.4 Repeated depressive episodes will increase the likelihood of further episodes. Approximately one-third of individuals with an episode of depression will have a recurrence within five years, with many going on to develop depressive episodes in adulthood. Further consequences may include impaired social, occupational and emotional functioning, as well as effects on physical health.
As in adults, severity of depression in young people is graded according to the number and range of symptoms present. It can range from mild through moderate-to-severe depression, when individuals are particularly disabled by the number and severity of symptoms.
In young people and regardless of severity, the first-line treatment for depression is specific psychological therapy. Guidelines produced by the National Institute for Health and Clinical Excellence (NICE) recommend individual therapies such as cognitive behavioural therapy (CBT), interpersonal therapy (IPT) or individual psychodynamic therapy. Group therapies such as group CBT or family therapy may also be appropriate. Although the absolute efficacy of psychological therapies might be considered disappointing, for example low rates of sustained improvement compared to control groups at one year follow-up, significant benefits can still be seen. The impact of an accelerated resolution of depression on an individual’s emotional and school functioning should not be underestimated, particularly when considering the life-long potential benefits that could follow from a speedy resolution.
Pharmacotherapy of depression in young people has been overshadowed by disappointing results combined with the small risk of fatal events. The increased risk of suicide and suicidal ideation has been most frequently associated with the use of selective serotonin reuptake inhibitors (SSRIs) in children and adolescents. Prior to these concerns, there was a noted risk of sudden cardiac death associated with tricyclic antidepressants (TCAs) in children and young people, although the reported cases centred on TCAs being used for non-psychiatric indications such as nocturnal enuresis.5 The combination of poor observed efficacy in clinical trials and risk of fatal events led the Committee on Safety of Medicines (CSM) to conclude that the risk–benefit balance for the treatment of depressive illness in under-18s was unfavourable for all SSRIs, with the exception of fluoxetine – the only antidepressant available at that time with demonstrated trial evidence for efficacy.6
Due to these concerns regarding a negative risk–benefit profile for antidepressants in young people, NICE recommended that medication should only be considered for depression of moderate or greater severity and then only in combination with one of the specific psychological therapies previously mentioned.1 It is recommended that close monitoring of response and adverse drug reactions is undertaken with antidepressants, with weekly contact between patient and professional for at least the first month. If psychological therapy is declined, medication can still be prescribed but more careful consideration needs to be made to follow-up monitoring as the necessary weekly contact is often made by the psychological therapist.
Pharmacological treatment versus psychological therapies
Since NICE made their recommendations in 2005, two large-scale studies have been published that looked at the place of drug therapy in the management of child and adolescent depression. The Treatment for Adolescents with Depression Study (TADS) was an American study funded by the US government.7 A total of 432 adolescents (aged 12–17 years) were recruited to receive one of four interventions in an initial 12-week acute period and then 36-week follow-up phase. The interventions were: fluoxetine alone; CBT alone; fluoxetine and CBT; and placebo alone (in the acute phase only). It was found that combined treatment with medication and CBT significantly accelerated the benefits. Given the potential consequences of untreated depression, such accelerated benefit could be advantageous, even if over time the differences were equalised. The addition of CBT to medication was found to reduce the incidence of treatment-emergent suicidality and was cost effective.
It was felt that TADS had limited applicability to depression care in the UK due to the types of patients that were excluded from the study and the method used to recruit participants. Although standard US recruitment practice was followed – using advertisements – such recruitment practice is associated with improved treatment response in trials. To overcome these issues, the Adolescent Depression Antidepressant and Psychotherapy Trial (ADAPT) was designed as a pragmatic randomised trial.8 ADAPT included individuals with persistent depressive symptoms that had not responded to brief psychological interventions or had been rated as severe from the outset. These inclusion criteria better reflected UK practice settings. In total, 208 adolescents (aged 11–17 years) with moderate-to-severe depression were recruited. All participants had failed to show response to a brief initial psychological intervention as part of the pre-trial screening. Participants received either therapy with an SSRI and routine care or therapy with an SSRI combined with CBT and routine care over an initial 12-week period. At the end of the acute phase there were no differences in effectiveness of treatment for either study group. In both groups, there was a decrease in suicidal thoughts and self-harm, although there was no evidence of CBT providing a protective effect. The study concluded that for adolescents with moderate-to-severe depression, there is no evidence that the combination of CBT plus SSRI contributes to improved outcomes.
In attempting to explain why the outcomes seen in the the ADAPT study differed from TADS, attention is drawn to the different protocols used by each study. Authors writing in support of TADS have commented that ADAPT used a population with more severe depressive illness and commented about the greater intensity and quality of CBT used in TADS.7 Also in ADAPT, participants in both study arms continued to receive routine clinical care that might have contained elements of CBT such as simple advice, cognitive restructuring, guidance for dealing with negative thoughts and the linking of depressive thoughts, behaviours and emotions. In TADS, these aspects of routine clinical care were discontinued.
In conclusion, there can be no doubt that young people experience and endure depressive illnesses. Although there are similarities with depression seen in adult patients, there are some key differences, particularly in the way in which individuals may present. Robust treatment is necessary if the risk of long-term disability is to be avoided. Evidence supporting individual treatment modalities is not strong and further work is necessary.
1. National Institute for health and Clinical Excellence (NICE) 2005. Depression in children and young people. Identification and management in primary, community and secondary care (CG28). http://www.nice.org.uk/CG28 (accessed 29 September 2011).
2. Goodyer I, Cooper PJ. A community study of depression in adolescent girls II: The clinical features. Br J Psychiatry 1993; 163: 374–80.
3. Herbert J et al. Adrenal secretion and major depression in 8 to 16 year olds, II. Influence of co-morbidity at presentation. Psychol Med 1996; 26: 257–63.
4. Beevers CG et al. Recovery from major depressive disorder among female adolescents: a prospective test of the scar hypothesis. J Consult Clin Psychol 2007; 75: 888–900.
5. Hazell P et al. Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis. BMJ 1995; 310: 897–901.
6. Committee on Safety of Medicines (CSM) 2004. Selective serotonin reuptake inhibitor (SSRI) antidepressants – findings of the Committee on Safety of Medicines (CSM). www.mhra.gov.uk/PrintPreview/DefaultSP/CON1004259 (accessed 29 September 2011).
7. March JS, Vitiello B. Clinical messages from the Treatment for Adolescents with Depression Study (TADS). Am J Psychiatry 2009; 166: 1118–23.
8. Goodyer I, et al. Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. BMJ 2007; 335: 142–46.