Vignette: Kayli
Kayli was 14 when her parent's arguments following their divorce 4 years earlier ‘got to her’. Her teachers
Symposium: psychiatryDepression in children and young people
Introduction
Depression represents a cluster of presentations characterized by disturbances of the body, affect and associated cognitions. The disturbances of the body, otherwise known as somatic symptoms or physiological symptoms, represent perturbations of the fight flight or freeze mechanisms and or of the motivational, appetitive and diurnal body clock systems, such as sleep and energy levels. These disturbances can be mapped using functional MRI (fMRI) to fronto-limbic and hypothalamic-pituitary systems and necessarily involve a range of neurotransmitter and neuro-hormonal correlates amongst which the serotonin, dopaminergic, noradrenergic, and melatonin, corticosteroid are prominent but probably only represent a partial understanding of the immensely complex brain chemistry at play.
The disturbances of affect manifest as over-arousal of generally negative emotional states like fear, anger, irritability and sadness. The cognitive and neurocognitive components are wider-ranging than many clinicians and educationalists recognize and include disturbances of attention, concentration, motivation, processing speeds, and generally ‘executive’ functions such as decision-making. In the most severe cases the fixed beliefs that emerge come close to or involve a psychotic depressive illness.
Depression is usually triggered by one or more negative events involving stress, loss, or disappointment; but they are not usually the entire cause. Additional risk factors categorised as vulnerability factors increase the impact of such adverse events, these may be difficulties in family relationships or friendships, long-term problems at school, difficult events earlier in life, and personality traits of the child/adolescent (including being a bit shy, being perfectionist and being more emotional than the average child).
There is considerable clinical and aetiological overlap between the anxiety disorders and depression. It is likely that the degree of overlap and the associated clinical heterogeneity represent the fact that current diagnostic groupings will require re-evaluation when the fruits of the new neurosciences become available.
Depression incidence increases sharply from early adolescence onwards. There are some specific incident onset differences from other childhood disorders with depressions showing escalating emergence from middle childhood and sharply upwards through adolescence into early adult life. At least 3% (range of study estimates 3–9%) of adolescents will develop depression in any 12-month period so in an average class of 30 adolescents, 1–2 will have clinical depression. There is gender ratio of 2:1 girls to boys in adolescents. In childhood, ages 7–11 years the rate is 1% and is equally common in boys and girls.
Early effective intervention is important to improve time to remission and prevent secondary illness effects such as poor physical health hygiene, education impairment, persisting relationship difficulties and complicating antisocial tendencies-delinquency. Depression is amendable to treatment. There are significant continuities for both depression and its secondary consequences, into adult life. This leads to one of the largest costs to society amongst all health conditions, across the world. Effective detection and treatment is vital.
Treatments generally start with psychosocial interventions and talking therapies, with medication used in selected and more severe subgroups. There are a few very severe subgroups where use of medication is advocated from diagnosis but never without good clinical psychosocial care. Subgroups requiring medication are defined by presentation severity and associated impairments, lack of response to first line talking therapies within specified time frames, deterioration during talking therapies, and overall presentation including comorbidities.
There is a limited role for laboratory or radiological investigations, but it is helpful to bear in mind that there are important disease processes which can result in low mood. Features in the history which suggest thyroid or cardiac disease should prompt further investigations e.g. thyroid function tests and ECG.
Section snippets
Assessment and management
Depression is a ‘common mental disorder’. In children and adolescents it can interfere with the developmental trajectory impairing educational experiences and close relationships (see Figure 1). In turn, this can have enduring consequences to self-confidence, self-worth, and capacity to form good relationships.
The secondary effects of depression in children and adolescents can persist into adult life and become risk factors for subsequent depressions, as well as onsets of adult personality
Detection and referral rates
Unfortunately, services are not very good at detecting depression in children and adolescents. Some reports have found up to 50% of cases presenting to GPs in UK NHS primary care are missed. Paediatricians probably fare little better. There is much to do! The features of depression are summarized in Box 1 (below).
Detection in primary care and subsequent referral rates from primary care to specialist care remain very low; no more than 25% of all cases of psychiatric disorder get any appropriate
What does depression look like?
A quote from Callum a mental health ambassador from Right Here Sheffield is very telling.
“I wish I knew before my GCSE years got wasted. I wish I knew before I got expelled, but I didn't and my life would have been better if I did. Teachers told me all the angles of a triangle add up to 180……but they never told me its ok to be depressed…not to feel ashamed…mental health is something we all have”
A missed opportunity to make a diagnosis of depression and take action can have profound consequences
How are the symptoms of depression expressed in everyday life?
The experience of depression is different for each young person and their family. Therefore, it stands to reason that the expression of the disease will also be different. In general, it is helpful to consider the expression of depression as mapping to one of four domains (Figure 2). Depression may lead to changes in thoughts, feelings, behaviours and physical experiences.
“Collateral damage” …the impact of depression
As Kayli's case exemplifies, depression often results in significant ‘collateral damage’ to the individual. This includes an increase in the frequency of ‘risk behaviours’. Thus for children aged 11–16 we see a significant increase in the risk of cigarette smoking, regular alcohol consumption, drug use and self-harm. Social isolation and school exclusion are also significantly more common (Table 2).
Impact into adult life – “Developmental Continuities”
Children and young people with clinical depression are at much increased risk of having significant mental health issues in adult life. Depression (generally these are clinic samples representing moderate or greater severity diagnoses) may recur in up to 50% or young people over 5 years and 75% over 18 years or more.
In fact 75 % of all mental disorder in adult life could be first detected in those under the age of 21 years and 50% in those under the age of 14 years.
Depression, suicide and self harm
There is a clear association between depression, suicide and self-harm. We know that depression is the most common diagnosis amongst those people who:
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Have committed suicide, indeed around 60% will have had depression prior to the event. This nevertheless remains a rare occurrence in the under 15s and relatively uncommon in the 15–24 years group, though a leading cause of death at this age, with less than 12 cases per 100,000 population, but up to four times more frequent in males than females.
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Initial assessment and case formulation
To facilitate treatment, it is important to firstly make an accurate assessment of the individual case. The following eight key points of assessment and intervention provide a framework to weave into standard clinical assessments and reviews and are derived from a standard form of psychosocial care called BPI (Brief Psychosocial Intervention).
They are
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Interpersonal effectiveness
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Expert understanding of mental states
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Adapting the culture of the assessment and case management to the core mental
Characterising depression
The core psychological states and complexes that are characteristic of depression include:
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Loss and grief processes leading to sadness, irritability, loss of energy and pleasure
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Inactivity
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Passivity
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Rumination
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Impaired problem solving
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Self blame, lowered self esteem
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Impairment of relationships and engagement with all forms of activities follows
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Systems get organised around passivity-withdrawal – inactivity
Screening tools for depression
Standardised interview based assessments and questionnaire are clinically useful tools to deploy
Consider and screen for comorbidities
In making any assessment it is important to consider the likely comorbidities. Generalized anxiety, OCD and other forms of anxiety affect between 30 and 80% of individuals. Self harm occurs in up to a third of moderate to severe cases. It is also important for eating disorders, substance misuse and be vigilant for psychotic-like symptoms with or without evidence of an evolving psychotic illness. If there is an episode of mania in the history then the depression may be particularly hard to treat
NICE approved interventions
The NICE guideline recommends we consider alternative treatment approaches depending on availability and individual preferences.
Psychosocial: good psychosocial care including assessment and engagement as a baseline for all further intervention. Such care should include self-rated questionnaire based assessment along with structured assessment of mental state. There is an emerging literature indicating that when such care is included within a comprehensive package including psycho-education and
What outcomes can be expected?
Amongst specialist clinic-referred cases with moderate to severe depression (ICD-10 or Major Depression in DSM-5), 20% will respond to the first 2–4 weeks of the assessment and early intervention processes in specialist care (early BPI for depression). Of those cases remaining depressed post initial intervention of 2–4 weeks, a further 50–60% will respond, over the next 12–28 weeks, to BPI for depression + medication. The shortening of a period of significant impairment may have very beneficial
Summary
Depression in children and especially amongst adolescents represents a serious public health issue and major challenge for services to deliver care to meet large unmet need in the UK. There is a considerable clinical and developmental imperative to change this situation because depression is a treatable condition, and untreated has short and long term adverse consequences including a significant contribution to youth mortality. Better understanding and knowledge of what works for these children
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