Depression in Younger People- a patient's guide

Dr Sally Merry | -Child Psychiatrist | Auckland New-Zealand

Abstract

This article provides an excellent overview of depression,with particular emphasis on younger people. Common symptoms and effective treatments are outlined and there is a self test questionnaire, which can be a useful tool to help clarify if depression may be present.

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What is depression? Doesn't everybody get depressed sometimes?

We all have times when we feel sad or stressed. There are times when day to day problems get us down. However these feelings are usually short-lived. This is not depression! When doctors use the term "depression" they are talking about an ongoing serious situation in which a person feels down most of the time for a long period, weeks or months, and sometimes years. When this happens it makes it difficult to keep up with everyday things. Work, school and social life can all be affected. Depression has an impact on appetite, sleep and the ability to concentrate and think clearly. Depression is also called "depressive illness", "major depressive disorder", "dysthymia' or "clinical depression".

Do children and teenagers get depressed?

We used to think that depression was something that only affected adults but over the last few years we have realised that depression can affect people at any age. Depression is not very common before the teenage years and children who get depressed usually do so because of the situation they are in. For example if the family is going through a hard time then the children in that family may become so miserable that is affects their ability to function.

Through the teenage years rates of depression increase markedly, especially in girls, so that by the age of 18 as many as one in five teenagers will have had an episode of depression, which is mostly untreated. We are not good at recognising depression generally, and we are especially poor at recognising it in teenagers. Part of the problem is that we expect teenagers to go through a difficult time. We expect them to be moody and irritable. However research has shown that while the teenage years can be unsettled, for the most part teenagers get through their adolescence reasonably well. We should not just accept it if a teenager feels miserable or irritable for most of the time, especially if this is making school and socialising difficult. We can improve things for these young people as we have developed very effective treatments for depression.

What causes depression?

Usually depression is the result of a number of things coming together and it is impossible to put it down to some simple factor. The causes of depression can be grouped into biological, psychological and social.

Biological

Depression is associated with a change in chemicals in the brain called neurotransmitters, which pass messages from one nerve cell to another. The two main neurotransmitters thought to be related to depression are serotonin and noradrenaline. These are decreased in people who are depressed. Medication works by increasing these substances.

Depression runs in families so that some people are born with an increased risk of developing depression. This tendency can be mild or severe and may only show itself if some of the other factors associated with depression come into play. For example someone who has family members who have suffered from depression may be more at risk for a depressive illness following a relationship break-up. In this way it is similar to illnesses like asthma, which also runs in families, can affect some more than others, and some not at all, and where the asthma attack is often set off by something like coming into contact with pollen, or the dust mite.

Psychological

We often think of feelings as things that happen to us over which we have no control. In fact the way we think about things affects the way we feel. People who have tendency to become depressed often feel very negative about themselves, about the world around them and about the future. They see little that is positive. Compared with someone who is not depressed they will tend to come up with more negative explanations for things that happen and are more likely to blame themselves when things go wrong.

People who are depressed are less likely to look for solutions to problems than people who aren't. They tend to give up more easily. This may be the result of stress early in life or it may be that they have just never learned skills to help them to solve problems.

These psychological findings are important as they have led to the development of highly effective psychological therapies.

Social

There are many stressful life circumstances that may contribute to depression. Family discord has been shown to be related to depression in children and young people. Other things that may contribute include loss experiences like losing a parent early in life, illness, especially chronic severe illness, abuse, and major trauma. War, colonisation and oppression may affect the mental health of large numbers of people in certain ethnic groups.

How to recognise depression

The sign of depression are:-

Low mood or irritability most of the time for more than two weeks
Difficulty with concentration
Change in sleep, either an increase or a decrease
Change in appetite, either an increase or a decrease
A drop in school grades
Reduced contact with friends
Loss of interest in usual activities
Suicidal thoughts or ideas

There is a self-test questionnaire at the end of this article which gives an indication of severity of depression if you are worried about yourself or someone else.

Treatment for depression

What you can do

If you or someone you know is depressed there are a number of simple things that might help

Being busy tends to improve mood. Even if it is an effort to begin, it is good to set goals and try and achieve them. If it is very hard going small goals are fine.
Scheduling enjoyable things is a good thing to do. Phoning a friend, playing sport, having a bath with music and candles, going to a movie, listening to music, watching a favourite TV programme are all things that may improve mood.
Getting enough sleep and eating sensibly are important.
Exercise improves mood. It increases the neurotransmitter serotonin, which is decreased in depressed people.
Telling someone about the problem is usually helpful. It allows someone to give support and they may have some good ideas for improving difficulties.
It is important to avoid alcohol, marijuana and sedatives generally. While these may make things better in the short-term they are depressants of the nervous system and will make depression worse. Illegal drugs generally have an adverse effect on people who are depressed.
You might like to try the self-help website http://www.feelbetter.org.

Where to go for help

If all these thing have been tried and there isn't improvement within a couple of weeks it is worth getting help. The best place to start is with your family doctor or school guidance counsellor who should be able to help, or to refer you to someone who can. Most places now have community child and adolescent mental health services that provide help for a variety of problems. You need a referral for many of these centres (which are listed in the phone books under mental health services in the hospital section of the telephone directory) but some will let you refer yourself. Staff at the centres will be able to give you advice about where to start in your particular area.

What treatments are available

There are a number of treatments available for depression. When deciding what treatment to use it is important that there is some evidence that the treatment works. This is important in treating physical illness like asthma and diabetes. It is also important in the treatment of mental illness. In depression there are many treatments described and used and not all of these have been tested well to see if they are working. They may be effective but there may not be any evidence for it yet. It is better to use a treatment which has been tested and is known to be effective.

What treatments work?

We have evidence that we can treat depression effectively and are able to improve things for 8 out of 10 young people. The treatments for which we have the best evidence are cognitive behavioural therapy (and the evidence is best for this), specific antidepressants and interpersonal therapy.

Cognitive behavioural therapy (CBT)

This therapy is based on the psychological factors that contribute to depression. It has two main components the cognitive, which deals with how people think and the behavioural, which addresses how people behave. It is essentially a systematic training in positive thought and action. It is a very practical therapy. Young people and their families are taught about depression and its causes. Mood is affected by what we think and what we do. Attention is paid to day to day activities and how they affect emotions. Activities that improve mood are scheduled. Negative ways of thinking are identified and more helpful ways of thinking are found. The person who does the therapy is the young person. The mental health professional is like a coach. It takes 12 &endash; 16 sessions that last about one hour each. Sometimes it is done in groups. CBT has been shown to work in adults and teenagers and probably helps to prevent depression coming back.

Medication

The most useful medications for young people with depression are called the SSRI's (specific serotonin re-uptake inhibitors). They work by increasing the brain chemical serotonin. They are effective in young people but take two to three weeks to work. They are taken once a day, usually in the morning. They are very safe medications and are not addictive but need to be stopped gradually so that the body can adjust to not having them. Side effects are worst in the first couple of weeks and this is a difficult time as the depression has not improved. It may be tempting to stop the medication in these early days but persevering with it is mostly worthwhile. Side effects improve with time. The most common side- effects are nausea, anxiety, difficulty sleeping, or excessive sleepiness. If one of these is too troublesome a change to another SSRI can sometimes sort things out. If medication has an effect, it should then be continued for at least six months before being stopped. Common SSRI's include fluoxetine (Prozac, Lovan), paroxetine (Aropax) and citalopram (Cipramil).

Interpersonal therapy

This is a psychological therapy that focuses on how the young person relates to those around him/her. It looks at ways that the young person can improve relationships with others. Theoretically it should work well, as we all know that conflict with those around us can make us feel negative and miserable. There is some evidence that it works for both young people and adults.

Cognitive behavioural therapy and medication work about as well as each other and if they are combined work better than either alone. As well as these therapies it may be important to address other things. Family conflict is an especially important area to deal with. If there are problems at school then these need to be dealt with. Specific counselling may be needed for specific difficulties such as abuse. Teenagers often abuse substances such as alcohol and marijuana. This will make the depression worse and will need specific attention.

While there are many other therapies used for depression, and some of these may be effective, we do not yet have scientific evidence that they work.

It is important to know that improvement takes time. Any therapy may take three or more weeks to start working and it can take two to three months before things get substantially better.

What happens over time?

If depression is not treated it can last for months or years. Once treated there is a high chance it will return (up to 70% of those who have had an episode of depression have another within 5 years). Recognising early signs that it is returning and managing these actively can reduce relapse rates markedly.

Depression and suicide

We( In New-Zealand) have one of the highest rates of youth suicide in the world. Parents are concerned for their teenagers and yet often feel powerless. Information about suicide and suicide attempts may be helpful.

Despite the media coverage or anecdotes it is known that over 90% of those who attempt or complete suicide have some form of mental illness. The most common illness is depression and it is mostly untreated. Other important problems include alcohol and drug abuse, aggressive and impulsive behaviour and high rates of family and social problems. It is important to realise that although our suicide statistics are high, suicide is still not common. In 1998 the rate for young men was 4 out of every 10 000 young men. Suicidal thoughts are very common in young people, some will attempt suicide and only a very small minority will complete suicide.

What can be done?

Suicidal thoughts are more common in young people who are depressed and it is important to talk about them. Many people are afraid that they may make things worse by talking about suicide. This is partly because we know that publicity about suicide can lead to an increase in those who kill themselves. There are some clear examples of young people killing themselves after suicide has been the topic in television shows or after a pop star has committed suicide. However there is no evidence that talking about suicidal thoughts with young people on an individual basis and out of concern for the young person leads to suicide or suicide attempts. It is an important part of managing young people who are suicidal and mental health professionals do it all the time. If you are feeling suicidal, tell someone! If you are worried that someone is suicidal, ask him/her! If the feelings are strong, get help! Your family doctor, a school guidance counsellor, a priest, a trusted older person are all good places to start. Where there is depression, effective treatment can usually get rid of the suicidal thoughts or at least reduce them to the point where they are not too troublesome. Many of the other underlying problems that contribute to suicidal thoughts can also be improved. It is better to address the problem than to hope it will solve itself.

Summary

Depression is common and usually starts in the teenage years. It is caused by a mix of factors including an inborn tendency, changes in chemicals in the brain, family and social problems and a pessimistic way of thinking. It is linked to poor school performance, difficulty with relating to other people, abuse of drugs and alcohol and suicide. Untreated, it goes on for months or years. There are effective treatments for over 80% of people with depression with cognitive behavioural therapy and medication the treatments of choice at the moment. There is a high rate of relapse so that it is important that any one who has suffered from depression knows how to recognise signs that it is coming back and how to deal with it if it recurs.

Test Your Depression

To determine how depressed you are, take this widely used test called CES-D (Center for Epidemiology Studies-Depression). It was developed by Lenore Radloff at the Center for Epidemiological Studies of the National Institute of Mental Health.

Write down the score for the answer that best describes how you have felt over the past week.

1. I was bothered by things that usually don't bother me.

0 Rarely or none of the time (less than 1 day)

1 Some or a little of the time (1-2 days)