Key learning points:
– Recognising depression in patients
– Promoting mental health as a healthcare professional
– Reducing stigma of mental health
Good mental health is a vital development of children and young people’s emotional wellbeing. Investment in this makes good economic sense as it reduces the cost of long-term ill health. Many adult mental health conditions show their first sign in childhood and almost half are estimated to begin during adolescence. If left untreated they carry increased risk of poorer outcomes in later life.
The problem requires a multi-faceted approach, with engagement from community, schools, employers, academia, colleges, healthcare providers, the pharmacy industry and users’ groups.
This article primarily aims to examine the prevalence of depression in children and young adults, its presentation, the referral pathways and evidence-based interventions. Nurses can make every contact count – promoting mental wellbeing for all is the first step towards service provision in schools, practices and communities.
Depression is one of the most significant public health problems in the 21st Century and is ranked as the third most frequent cause of consultation in general practice.1 Not only does it impact an individual’s wellbeing, it also affects their ability to study or work and their personal relationships – which has an impact on education attainment and the national economy. Mental health problems are estimated to cost £105.2 billion in lost productivity and other health-related costs.2 Being a common condition, it generates a high demand on all primary care services.
Depression is often highly treatable but just one-in-four children and young people receive the support they need.3 According to one study4 only 18 to 34% of young people with severe depression or anxiety symptoms seek professional help. There is a growing trend in the UK of young people reporting frequent feelings of depression or anxiety.5 Nuffield Foundations reports that:
– Nearly 80,000 or 0.9% of children and young people are seriously depressed.
– More than 8,000 or 0.2% of children aged five to 10 years are seriously depressed.
– Some 62,000 or 1.4% of 11 to 16-year-olds are seriously depressed, with girls reporting depression more than boys.
People with physical illnesses often also have mental health problems, particularly acute depression. They die 20 years earlier than the general population as depression increases the risk of premature mortality by 50% and doubles the risk of coronary heart disease in adults.6 It is therefore suggested that mental health problems and physical illnesses are interwoven. The recognition and treatment of depression in primary care by non-specialist practitioners may not always be adequate due to a lack of mental health education and training in depression screening.7
Other barriers that prevent young people getting professional help include perceived stigma, lack of parental support, and structural and cultural failures in the healthcare system. In Australia, a qualitative study8 reported a shortage of information for young people to understand depression and its treatment. It is important that mental health professionals, including nurses, respond effectively to increase young people’s awareness and reduce stigma. Primary care professionals and community nurses can help by being more systematic in recognising depression in these patients, providing ongoing support, making appropriate referrals to GPs and signposting to specialist services when necessary.
Psychological impact of depression
It has been well documented that quality of parenting and family conditions affect children’s physical and emotional growth.
Poor secure attachment, neglect, lack of quality stimulation and conflict all negatively affect future social behaviour, educational outcomes, employment status, and can lead to mental and physical health problems. There are also links between depression and exposure to domestic violence, various forms of child abuse, cyber-bullying and other related adversities.
More than 900,000 young people aged 16-24 are not in education, employment or training. Prolonged unemployment increases the incidence of psychological problems from 16 to 34%. They are also more likely to experience poor long-term health, according to the Department of Education.9
Pre and perinatal experiences
The prenatal period has a significant impact on a newborn’s physical, mental and cognitive development. Maternal health is particularly important as poor environmental conditions, poor nutrition and health, smoking, alcohol and drug misuse, stress and highly demanding physical labour can all negatively affect the development of the fetus and later life outcomes.10
Children of depressed mothers are also at a greater risk of being underweight and stunted and may develop depression in later life.11
Prevalence rates of postnatal depression in mothers are estimated to be between 5-25%, although the actual figure varies from study to study.12,13 Recent research14 suggests 10% of men are affected by prenatal and postpartum depression, which is higher in the three to six months postpartum. Paternal depression also showed a moderate positive correlation with maternal depression. All women should be asked about their mental health during pregnancy and postnatally. Community midwives and health visitors with specialist training are ideally placed to identify depression at postnatal visits. Health visitors working in children’s centres need to be confident in detecting, discussing and dealing with postnatal depression and to ensure the right specialist provision is in place. Providing education to women and new mothers can help manage problems such as infant mortality, stunting and malnutrition, conduct problems, and emotional and mental health problems.
Self-harm and suicide in young people
Depression is also the leading cause of self-harm and suicide among adolescents. The rates of self-harm are high between the ages of 12 and 15 years of age. Girls are five or six times more likely to self-harm than boys but the ratio levels off in later years.15 However, self-harm behaviour is largely hidden and is a major predictor of subsequent suicide.16 Usually self-harm does not present to clinical services at community level, partly due to stigma, so any reported figures should be perceived with caution. Currently, there is no robust evidence of what reduces or prevents self-harm in adolescents, so it is impossible to recommend any interventions.
Suicide is most commonly associated with mental health problems such as anxiety, depression and substance misuse. Global figures17 predict suicide as the second leading cause of death in people aged 10 to 24 years of age, with the first leading cause being road traffic accidents. Male adolescents are more likely to die by suicide than their female peers, and the suicide rate in male adolescents aged 15 to 19 is 2.6 times that of female adolescents of the same age.18 However, the figures do not include suicide attempts, which are 20 times more frequent than completed suicide. The latest figures on suicide rates from the Office of National Statistics (ONS) reported 4,722 suicides among people aged 15 and over registered in England in 2013, 215 more than 2012. Of these, more than three-quarters (78%) were male (3,684 deaths, compared with 1,038 for females). For Wales in 2013, there were 393 suicides in those aged 15 and over, a rise of 59 deaths since 2012. Between 2012 and 2013, the number of male suicides rose by 23% from 257 to 317, while the number of female suicides dropped very slightly from 77 to 76, according to the ONS.
Suicide is complex and involves biological, social, psychological, psychiatric, cultural and environment factors and has been linked to depression.19 Suicide risk factors specific to young men include psychiatric disorder, substance misuse, ethnic origin, single marital status, youth unemployment, sexual orientation (LGBT), social deprivation and social fragmentation.20 Among people in employment, some occupational groups are at increased risk of suicide, for example, medical practitioners (particularly young female doctors and nurses) and several high-risk groups such as dentists, pharmacists, veterinary surgeons and farmers who have easy access to means of suicide.21
In addition, death by suicide can have a devastating effect on families and communities. Family and friends bereaved by a suicide are at increased risk of mental health problems themselves. The improvement of care and support for families who have been affected by suicide is a key objective.
The Department of Health suicide prevention strategy22 aims to reduce suicide in key risk groups, including people in the care of mental health services, people with a history of self-harm, and people in contact with the criminal justice system. It aims to improve data collection and monitoring, support research, reduce access to the means of suicide, respond to people in distress, improve the NHS response to suicide, to develop the evidence base and to support change and improvement. Primary care nurses and other healthcare professionals should always directly ask patients with depression about suicide ideas and intent, including whether they have adequate social support and whether they are aware of sources of help if the situation deteriorates. Public Health England23 shows that suicide risk factors can be assessed by motivational interviewing techniques and effective communication such as active listening and building rapport and empathy.
Primary care nurses can identify children and young adults with depression. They can listen to and support them; communicate concerns; refer with consent to services and agencies that can help them improve health and wellbeing, and identify realistic and achievable improvements. Leading a change in mental health promotion is every nurse’s business.
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9. Department for Education. Annual benchmarking data on the number and proportion of 16-18 years olds not in education, employment or training (NEET) across local authorities. Department for Education publications, 2013.
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19. Hawton K, Heeringen K. Suicide Seminar. The Lancet, 2009.
20. Royal College of Nursing, Public Health England. Preventing suicide among lesbian, gay and bisexual young people: A toolkit for nurses, 2015. gov.uk/government/uploads/system/uploads/attachment_data/file/412427/LGB_Suicide_Prevention_Toolkit_FINAL.pdf (accessed 29 April 2016).
21. World Health Organization. World Suicide Prevention Day, Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope, 2012. iasp.info/ (accessed 29 April 2016).
22. Department of Health. Preventing suicide in England. A cross-government outcomes strategy to save lives. Crown copyright 2011, First Published September 2012.
23. Department of Health, Public Health England. Future in mind. Promoting, protecting and improving our children and young people’s mental health and wellbeing. Crown Copyright DH, 2015.