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'I just don't care anymore' - managing adolescent depression

Dr Jenni Watson speciality doctor in child psychiatry and Dr Bindu Poornamodan, consultant CAMHS psychiatrist, discuss this case of a despondent, socially isolated teenager

Case

A 15 year old year 11 student is brought to the GP by her parents as they have noticed a two month decline in her personal hygiene alongside a loss of interest in friends, school and hobbies. She is spending most of her time in her bedroom and has not completed any of her school coursework, which, as an A* student, is very unlike her. When with her family she is described as ‘snappy and irritable’. Her mum is known to the GP with a history of mild depression.

On review by the GP, the patient is flat and responds with only minimal answers. She is dressed appropriately although is wearing no make up, which her parents say is unusual for her. She reports having no energy and that she has been struggling to sleep for the last two or three months. She denies that she is worried about anything but says that this is because she doesn’t really care about anything anymore. On further questioning she reveals that she has been scratching her arms with a pencil sharpener for the last six months and her parents are shocked to hear this. She says it makes her feel better for a short time. She thinks that life is not worth living most days but denies that she has any plans to end her life. She would like help to feel better but doesn’t believe she ever will.

Her GP suspects depression and refers her to the community CAMHS team for assessment.

The problem

It is estimated that 10% of 5-16 year olds have a clinically diagnosable mental health problem.1 Depression is thought to affect a quarter of young people, with a rise in incidence in mid to late adulthood.

One in 12 young people regularly self-harm, with rates higher in girls than boys. Depression itself has a higher incidence in males despite a suspicion that depression is under-reported by young males. Depression and its comorbidities can lead to disruptions in education, social interactions and family relationships. Young people with mental health problems are also more likely to use substances. Even sub-clinical depression in young people can increase the risk of adult depression 2-3 fold.2

Risk factors for the development of depression include3:

  • Family history of mental health problems.
  • Adverse life events – bereavement, bullying, school-related stress, trauma.
  • Familial discord or difficulties – separation, loss, financial difficulties, abuse, looked after status.
  • Ethnicity and culture – including refugee and asylum status.
  • Chronic or comorbid physical health problems.
  • Substance abuse.

It is vital that depression is identified and managed early as suicide is currently the most common cause of death for males aged 5-194 and the second most common for females. Estimates suggest that over two-thirds of young people do not receive appropriate treatment from the onset of difficulties and in fact treatment is often significantly delayed.

Features

Depression in children and adolescents is similar to that in adults with pervasive low mood, loss of interest and loss of energy as the three core features.

ICD-10 provides the following diagnostic classification for depression:

Core featuresOther features

Depressed mood

Loss of interest and enjoyment in previous activities and interests

Increased susceptibility to fatigue/reduced energy

 

Poor concentration and attention

Poor self-esteem/self-confidence

Feelings of guilt and unworthiness

Bleak and pessimistic view of the future

Ideas or acts of self-harm or suicide

Disturbed sleep

Disturbed appetite

In terms of severity:

  • Mild: at least two core features and two ‘other’ features.
  • Moderate: at least two core three ‘other’ features.
  • Severe: three core and four or more ‘other’ features with or without psychotic symptoms.

Other features that may be more widely reported in young people include irritability, anger and somatic complaints (primarily headache and stomach ache).

Clues that may point to depression in young people include decline in school performance or attendance, withdrawal from previously enjoyed hobbies or groups (social or academic), social isolation, altered peer or family relationships (for example increased arguments) and poor personal care (for example, less care given to clothes, grooming, make up).

Diagnosis

Depression is a clinical diagnosis but it is important to rule out any medical causes (hypothyroidism, hypocalcaemia, anaemia, B12 deficiency for example) regardless of whether biological symptoms are reported or not. Assessment should take place with the young person at the forefront but collecting collateral information from family or carers is advised. It is imperative when reviewing young people that comparisons are made between pre- and post-morbid personality as this often provides a wealth of information.

Core and ‘other’ features of depression should be explored alongside detailed discussions of:

  • Education - stressors, bullying, attendance, achievement levels.
  • Home/family – mental health problems, relationships, socioeconomic difficulties.
  • Abuse – current and historical.
  • Substance misuse.

Assessment of suicidality, deliberate self-harm and the presence of psychotic symptoms are also vital. It is important that parents are aware of any identified risks.

Screening questionnaires such as PHQ or HONOS can be used in general practice but this should not take the place of clinical assessment. Cut-off points for referral into CAMHS may differ so an understanding of local protocol for assessment is important.

Management

Mild depression

In cases of mild depression, where there are no risk factors (risk of harm to self or others), a two week ‘watchful waiting’ period is advised. Follow up at two weeks should be proactive and the reasons for DNA should be explored. If symptoms are self-limiting within that time period no further follow up is needed. Those who continue to have symptoms should be reviewed again in two weeks.

For those who do require earlier intervention due to risk factors, or for those who still have symptoms after four weeks, all therapeutic options should be discussed with the patient and their families. There is no evidence that one psychological therapy is better than another and current options include individual non‑directive supportive therapy, group CBT or guided self‑help for a limited period (approximately 2-3 months). These are usually available via tier 2 services (specialists within the community setting such as primary mental health workers, school counsellors or younger minds). If there is no response after 2-3 months then care should be stepped up to tier 3 (specialist CAMHS multidisciplinary teams).

Moderate to severe depression

These young people should ideally be reviewed within a CAMHS service. Initial treatment should be with a specific individual psychological therapy for at least three months.

Medication can be considered if symptoms are unresponsive to psychological therapy after 4-6 sessions. The usual first line choice would be fluoxetine at 10mg daily. The evidence for use of antidepressants in the 5-11 age group is not well established at present.

Medication should only be offered in combination with concurrent psychological therapy, however in some circumstances medication alone may be considered. Careful monitoring needs to take place as there is a risk of worsening mood and increasing suicidality with the use of SSRI medication, ideally contact should be weekly for the first four weeks. Other side effects include gastrointestinal disturbance, postural hypotension and sleep disturbance. Medication should be initiated and monitored by a CAMHS psychiatrist.

Depression not responding to treatment

Poor response to treatment should result in an MDT review to look at any coexisting factors including mental health, physical health and environmental triggers. Alternate or add-on therapy should be considered in these cases - systemic family therapy or individual child psychotherapy are possible options. Admission may be considered if it is felt that risk cannot be managed within the community or symptoms are too severe to manage in the community. The Mental Health Act may need to be considered if young people decline admission.

Dr Jenni Watson is a speciality CAMHS doctor for North Stoke CAMHS. Dr Bindu Poornamodan is a consultant CAMHS psychiatrist at North Staffordshire Combined Health Care.

References

  1. Fundamental facts about Mental Health 2005: Mental Health foundation
  2. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN. Prevalence of and Risk Factors for Depressive Symptoms among Young Adolescents. Arch Pediatr Adolesc Med. 2004;158(8):760–765. doi:10.1001/archpedi.158.8.760
  3. Rutter, M. & Taylor, E. (eds) (2002) 'Child and Adolescent Psychiatry' (4th edn). London: Blackwell
  4. ONS Data 2016
  5. NICE guidelines – Management of depression in children and young people- September 2017

 

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Readers' comments (3)

  • https.//www.accessdata.fda.gov

    The FDA Full Prescribing Information for Fluoxetine reads as follows:

    17.2 Clinical Warning and Suicide Risk.

    "Patients, their families and their care givers should be encouraged to be alert to the emergence of anxiety, agitation, anxiety, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, other unusual changes in behaviour, worsening of depression and suicidal ideation, especially earl during antidepressant treatment or when the dose is adjusted up or down'.

    "Families and caregivers should be advised to look for the emergence of such symptoms on a day to day basis since such changes may be abrupt".

    "Such symptoms should be reported to the patients prescriber or health professional, especially if they are severe, abrupt in onset or were not part of the patient's presenting symptoms".

    "Symptoms such as these may be associated with a risk of increased suicidal thinking and behaviour and indicate a need for very close monitoring and possibly changes in the medication".

    Akathisia is not well described as psychomotor restlessness.
    It has been reported to occur to a level of clinical significance in 20% of patients treated with SSRIs.

    The intensity of this SSRI neurotoxicity may be so great as to result in a writhing, pacing, a tormented, incoherent patient, in desperation for relief pulling out clumps of scalp hair, eyelashes, even pubic hair (or rather tearing out body hair in anguish).

    The overwhelming and terrifying agitation in severe akathisia is devastating for patient and family.

    Reporting to the prescriber may lead, in good faith, to a diagnosis of S.M.I with detention and enforced drugging leading to even more severe agitation, akathisia and risk of serotonin syndrome.

    How might we be made more aware of this life threatening neurotoxicity?

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  • Refer to CAMHS??? In your dreams, they’ll bounce that back to you faster than Federer.
    Prescribe SSRI to a teenager with its increased suicide risk? Risky, folks, very risky!
    Frankly your best bet is to wait for them to reach 18 when they can at least be seen by adult services.
    The paucity of treatment for adolescent depression is a national disgraceful.

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  • Disgrace, not disgraceful, damned autocorrect!!

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