Key learning points
- Primary care nurses are well placed to identify and support young people with this common mental health condition
- The core symptoms of depression in children and young people can be similar to those in adults
- Children and young people who have experienced one episode of depression are more likely to experience it again in later life
The primary care nurse is vital in the early detection and management of children and young people who are depressed. The nurse could potentially be the first point of contact when a parent, education or social care professional is concerned about a young person’s mental health. However, because of the heterogeneity of presentations, healthcare professionals may struggle to recognise depression.[1] Therefore, it is important that possible symptoms are assessed, not overlooked.
Signs and symptoms
Depression in children and young people is an especially current issue because Prime Minister Theresa May announced a major review of Child and Adult Mental Health Services (CAMHS) early this year.
Adolescence is often viewed as a time of emotional turmoil and it is seen as normal for most young people to experience occasional periods of sadness and despondency. However, clinical depression is very different from this. In order to receive a diagnosis of depression, the young person has to meet certain criteria.
Depression is one of the common mental health problems in children and young people, although it is uncommon in prepubertal children, with prevalence rates of between 1-2%.[2] The overall lifetime and 12-month prevalence of major depressive disorder (MDD) for adolescents aged 13-18 is 11% and 7.5% respectively. The corresponding rate for severe depressive disorder is 3% and 2.3%.[3] However, depressive symptoms are much more common – up to 29% of adolescents experience depressive symptoms and these are also associated with impairment and suicidality.[4]
Rates of depression differ between boys and girls and the marked rise in depression in older children has been attributed to the increasing prevalence of depression in adolescent girls – a sex difference that persists into adulthood.[5] For a diagnosis of depression, the young person must display at least five of the nine symptoms in addition to impairment in functioning. One of the core symptoms must be present at all times: low mood, irritability or marked diminished interest or pleasure in almost all activities. Another key is that the symptoms of depression cannot be attributed to only the effects of substance misuse, medication, a medical condition or bereavement.
Depression in adolescence is complex and often presents with other mental health conditions, such as anxiety or conduct disorders. The presence of comorbid disorders generally indicates a poorer outcome in relation to suicidality, duration of depression, risk of recurrence and impairment. Depression in childhood and adolescence is a serious illness that requires immediate professional evidence-based treatment.
The core symptoms of depression in both children and adolescents are similar to those seen in adults, although there are significant differences.[6] Depression in young people is associated with increased suicidality and worse outcomes than depression of adult onset.[7] The clinical presentation is dependent on developmental stage: for example, younger children may present with somatic symptoms, such as tummy aches and headaches, as well as behavioural changes, such as refusing to go to school and separation anxiety,[8] whereas older children may present as ‘bored’, irritable and oversleeping, and demonstrate significantly more hopelessness and helplessness, lack of energy, weight loss and suicidality.
The nurse’s role
The National Institute for Health and Care Excellence (NICE) recommends that CAMHS should work with primary care professionals to develop systems for detecting, assessing and supporting children and adolescents who are depressed. The report of the Children And Young People’s Mental Health Task Force [9] recommends greater system co-ordination with a focus on liaison between schools and primary care. Given both the serious and far-reaching consequences of childhood and adolescent onset depression, there is an urgent need to improve both the screening and treatment of this population in the early stages of the disorder [3] to ensure the best possible outcomes.
Primary care nurses should, in collaboration with the young person and their families, refer to a GP and consider a referral to specialist CAMHS if a child or young person is either not responding to NICE-recommended initial interventions, or refer urgently if they have a moderate to severe depressive disorder with suicidal thoughts or self-harm. A recent longitudinal study demonstrated the importance of early referral to CAMHS. In this study, adolescents at age 14 with depressive disorder who had contact with CAMHS had a greater decrease in depressive symptoms when compared to those who had no contact; by age 17, those who had no contact were seven times more likely to report depressive symptoms than those who had contact.[10] The findings demonstrate the importance of early specialist referral and intervention.
There are a number of screening instruments available, but there is limited consensus regarding their use.[11] However, research has demonstrated that if the young person answers ‘yes’ to the following questions, this could be as effective as a screening tool: ‘Over the past two weeks, have you felt down, depressed, or hopeless?’ ‘Have you felt little interest or pleasure in doing things?’[12]
Impact on young people and their families
Children and adolescents who have had one episode of depression are at future risk of a further episode with continuation into adulthood, and poor psychosocial functioning. [13] In clinical samples, the risk of further episodes is between 50-70%.[14] If not managed, depression can lead to a number of complications and may have a profound impact on the young person and their families. Children who experience depression face a range of negative outcomes including school refusal, academic failure, impaired peer relationships, family relationship problems, drug and alcohol misuse in addition to other risky behaviour including under or overeating, smoking, underactivity and unprotected sex.[15]
Management of adolescent depression
Initially, for mild depression, NICE [1] recommends ‘watchful waiting’ for a period of up to four weeks as a first-line approach. If this is unsuccessful, non-directive supportive therapy, guided self-help or group cognitive behavioural therapy (CBT) should be offered.
In cases of moderate to severe depression a psychological therapy should be offered. NICE [1] recommends individual CBT interpersonal therapy, family therapy or psychodynamic psychotherapy as evidence-based psychological approaches in the treatment of moderate to severe depression.
However, there is limited evidence to suggest that one type of psychological therapy is better than another. A recent trial investigating treatment outcomes in depressed adolescents found no evidence to demonstrate the superiority of CBT or short–term psychoanalytical therapy when compared with a brief psychosocial intervention.[17] In relation to antidepressants, fluoxetine in combination with a psychological treatment is recommended by NICE as a first-line step in pharmacological management.
One of the most worrying complications of depression is its association with suicidality.[3] Mood disorders are a leading cause of suicide in young people,[18] therefore it is essential that assessment and treatment takes place in a timely and efficient manner.[1] Primary care professionals have a key role. NICE [1] recommends that primary care professionals should have the training and knowledge to recognise children and adolescents who may be at risk of depression, in addition to recognising known factors associated with a high risk of depression such as homelessness, refugee status and living in institutional settings. In addition to psychosocial risk factors there are also a number of known resilience factors.
The treatment of parental depression is also vital in the management of child and adolescent depression, and support for a parent may need to be considered. A study that examined interventions to prevent depression demonstrated that treatment of parental depression was one of the most important factors in the prevention of depressive episodes in offspring.[19] Treatment of maternal depression is also associated with a significant improvement in the child’s depression.[19] However, multiple protective factors are also required to reduce the risk of mental health problems in children of depressed parents (zero or one protective factor, 4% sustained good mental health; two protective factors, 10%; three protective factors, 13%; four protective factors, 38%; five protective factors, 48%).[16]
The primary care nurse should be aware of what self-help services and resources are available locally, such as information leaflets and online resources, helplines and family support groups.
Conclusion
Depression is a common mental health problem in young people. Contact with a primary care nurse offers important opportunities for early intervention to help improve their lives and prevent some of the serious, long-term consequences.
References:
1 National Institute for Health and Care Excellence clinical guideline 28. Depression in children and young people: identification and management in primary, community and secondary care. 2015 nice.org.uk/guidance/cg28
2 Angold A, Costello EJ. Epidemiology of depression in children and adolescents. In: Goodyer I (ed). The depressed child and adolescent, 2nd ed. Cambridge University Press, 2001:143-78.
3 Avenevoli S, Swendsen J, He J-P et al. Major Depression in the National Comorbidity Survey – Adolescent Supplement: Prevalence, Correlates and Treatment. Journal of the American Academy of Child and Adolescent Psychiatry 2015;54:37-44.e2. doi:10.1016/j.jaac.2014.10.010.
4 Balázs J, Miklósi M, Keresztény Á et al. Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk. Journal of Child Psychology and Psychiatry 2013;54:670-7.
5 Collishaw S. Annual Research Review: secular trends in child and adolescent mental health. J Child Psychol Psych 2015;56,370-93.
6 Kaufman J, Martin A, King RA et al. Are child-adolescent, and adult onset depression one of the same disorder? Biological Psychiatry 2001;49:980-1001.
7 Zisook S, Lesser I, Stewart JW et al. Effect of Age at Onset on the Course of Major Depressive Disorder. Am J Psychiatry 2007;164:1539-46.
8 Yorbik O, Birmaher B, Axelson D et al. Clinical characteristics of depressive symptoms in children and adolescents with major depressive disorder. J Clin Psychiatry 2004;65:1654-9.
9 Future in Mind: Promoting, protecting and improving our young people’s mental wellbeing. Department of Health 2015.
10 Neufeld S, Dunn V, Jones B et al. Reduction in adolescent depression after contact with mental health services: a longitudinal cohort study in the UK. Lancet online 2017 dx.doi.org/10.1016/S2215-0366(17)30002-0
11 Simmons M, Wilkinson P, Dubicka B. Measurement Issues: Depression measures in children and adolescents. Child and Adolescent Mental Health 2015;20:230-41.
12 Chung P, Soares NS. Childhood Depression: Recognition and Management. Consultant for Pediatricians 2012;11:259-67.
13 McLeod G, Horwood L, Fergusson D. Adolescent depression, adult mental health and psychosocial outcomes at 30 and 35 years. Psychological Medicine 2016;46:1401-12.
14 Dunn V, Goodyer IA. Longitudinal investigation into childhood and adolescence-onset depression: Psychiatric outcome in early adulthood. British Journal of Psychiatry 2006;188:216-22.
15 Thaper A, Collishaw S, Pine DS et al. Depression in adolescence. Lancet 2012;379:1056-67.
16 Collishaw S, Hammerton G, Mahedy L et al. Mental health resilence in the adolescent offspring of parents with depression: A prospective Longituninal study. Lancet Psychiatry 2016;3:49-57.
17 Goodyear IM, Reynolds S, Barrett B et al. Cognitive behavioural therapy and short-term-psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet online 2016 dx.doi.org/10.1016/s2215-0366(16)30378-9.
18 Windfuhr K, While D, Hunt I et al. Sucide in juvenilles and adolescents in the United Kingdom. Journal of Psychology and Psychiatry 2008;49:1155-65.dn
19 Brent DA, Brunwasser SM, Hollon SD et al. Effect of cognitive-behavioural prevention program on depression six years after implementation among at-risk adolescents:
a randomized clinical trial. JAMA Psychiatry 2016;72:1110-18.
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