Management of depression in young people

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1 Management of depression in young people A guide for primary care health professionals For young people not in immediate danger of suicidal behaviour, management of major depressive disorder is likely to include a number of approaches, starting with psycho-education and supportive management, with the addition of psychological therapy. Pharmacological treatment (e.g. antidepressant medications) may be warranted in certain situations. The length of treatment required for effective remission varies depressive conditions may require up to 36 weeks of active treatment. Before treatment is discontinued, factors that may contribute to relapse and recurrence need to be addressed. Decision-making about management The aim of management is to achieve a reduction in depressive symptoms and return to functioning, then an absence of significant symptoms for a defined period of time. Primary care health professionals should support young people and their families to choose appropriate treatments, taking into account the severity of symptoms and any co-occurring conditions, as well as the young person s circumstances, preferences and resources. To inform decision-making, the young person should be given relevant and culturally appropriate information about treatment options, with full discussion of their suitability and acceptability to him or her. It can be useful to involve parents/carers/partners in discussions, according to the young person s wishes. Psychological therapy (specifically Cognitive behavioural therapy (CBT) and Interpersonal psychotherapy (IPT)) and pharmacological treatment (specifically fluoxetine) are both effective in treating major depressive disorder in young people. Unless symptoms are severe, CBT or IPT should be first-line treatment for all young people with major depressive disorder. The dangers of not treating moderate to severe depression should be highlighted, as depression is the major risk factor for suicide. 1 of 4

2 Management of depression in young people Principles for managing depression in young people Psychosocial support Keep building the therapeutic relationship, in particular ensuring that services are welcoming, and adopt an honest, empathic and non-judgemental approach. Involve the young person and parents/carers in developing the management plan and consider physical, mental, family, social, spiritual and cultural factors relevant to the young person. Provide a good standard of care at all times by continuing contact, discussing symptoms and problems, and encouraging a collaborative approach. Psychological therapies Consider suitability of the therapy for the individual young person taking into consideration his or her preferences, age, education level, intellectual capacity, language and/or cultural factors and motivation. Discuss the chosen therapy (e.g. number of sessions, homework, costs) with the young person and his or her parents/carers/partner. Only provide therapy if trained in the relevant therapy and experienced in working with young people. Apply the therapy in line with evidence-based practice manuals. Monitor adherence to therapy tasks and enhance therapy adherence. Provide therapy for an adequate duration most CBT and IPT programs range from 10 to 16 sessions. Adapt/review therapy if the young person is unresponsive. Pharmacological treatment Only prescribe medication if you are trained to do so or have sought advice, familiar with the range of adverse effects and able to closely monitor the young person, particularly during the first 4 weeks of treatment. Take into account the young person s preferences, the risk of adverse effects, response to previous treatments, convenience and psychosocial stressors that may maintain the depression. Support informed decision-making by providing appropriate information on adverse effects, the possibility of the emergence or escalation of suicidal thinking and the need for ongoing monitoring during treatment. Continue medication therapy for 6 months post-remission. 2 of 4

3 Key actions in response to diagnosis Diagnosis and actions for primary care health professionals Involved Symptoms of depression Information Provide youth-friendly information about depression, its causes and treatments (e.g. beyondblue fact sheets) Guided self-help Provide advice on self-help strategies (e.g. online CBT) Primary care Non-directive support Use active listening, person-centred discussion and empathy Lifestyle advice Provide advice on sleep, relaxation and physical activity Dysthymia or mild major depressive disorder Psychosocial support Primary care and/or Consider non-directive support, guided self-help, group CBT specialist support Mild to moderate major depressive disorder Psychosocial support Consider non-directive support, guided self-help, group CBT Primary care and/or Psychological therapy Consider CBT or IPT if available mental health service Moderate to severe major depressive disorder Psychological therapy Consider CBT or IPT if available Primary care and mental Medication (see Table 1) health service and/or Consider fluoxetine if necessary psychiatrist Severe major depressive disorder Psychological therapy Consider CBT or IPT if available Psychiatrist, specialist Medication (see Table 1) Consider fluoxetine to reduce symptoms in the short-term mental health services Depression unresponsive to treatment/recurrent depression Referral Refer for intensive psychological intervention Psychiatrist, specialist Medication (see Table 1) Consider fluoxetine if necessary mental health services Depressed phase bipolar disorder Referral Psychiatrist, specialist Refer to or consult a specialist in the field for individual advice mental health services Psychotic depression Referral Refer urgently to specialist services Inpatient care Psychiatrist, specialist Consider a more intensive treatment setting mental health services Re-evaluation Consider alternative diagnosis (bipolar) Notes: CBT=cognitive behavioural therapy; IPT=interpersonal psychotherapy 3 of 4

4 Table 1 Considerations if medication is prescribed Consider the SSRI fluoxetine for treating moderate to severe major depressive disorder, where psychological therapy has not been effective, is not available or is refused, or if symptoms are severe. Do not initiate other antidepressants, including TCAs. Closely monitor symptoms and adverse effects, especially during the first 4 weeks after initiation of fluoxetine. Have a protocol for managing suicidal thinking for every young person taking fluoxetine, including baseline assessment and regular monitoring for suicidal thinking. Be aware that a manic episode may be precipitated following initiation of SSRIs. Notes: SSRI=selective serotonin reuptake inhibitor; TCA=tricyclic antidepressant Resources for health professionals Clinical practice guidelines for depression in adolescents and young adults Assessment and management of depression in young people: A guide for primary care health professionals Depression in young people A guide for primary care health professionals Fact Sheet Engaging young people in health care: A guide for primary care health professionals Depression in young people: A desktop guide for primary care health professionals BL/1034_1012 The information in this fact sheet is derived from the beyondblue (2011) Clinical Practice Guidelines: Depression in adolescents and young adults. Melbourne: beyondblue, the national depression and anxiety initiative. Beyond Blue Ltd 4 of 4

5 Assessing depressive symptoms in young people A guide for primary care health professionals When young people are experiencing distress or depressive symptoms, there may be explanations other than depression, such as grief and loss, trauma or distressing life events, or difficulties in expressing and managing anger, sadness, fear and shame. The assessment process involves helping young people to make sense of their experience of normal feelings and reactions, as well as identifying the presence and assessing the severity of symptoms. A diagnosis of depression, when it is indicated, should not be seen as a label, but a flag to guide further actions by the health professional and the young person, and his or her parents or carers. The assessment process comprises: an initial assessment that aims for understanding of the young person s developmental, familial and sociocultural context as well as his or her mental state assessment for depressive symptoms, which may involve the use of assessment tools, and includes considering other mental health and physical conditions that may cause depressive symptoms. Assessment for risk of suicide is an immediate task if depressive symptoms are identified in a young person, with involvement of parents/carers where possible. Considerations in assessing depression in young people Engaging young people is necessary so that they feel sufficiently trusting to give a history of their current challenges and difficulties. It is important to explain confidentiality policies fully to young people in their first session and to outline the information that will be shared if confidentiality has to be breached. With the young person s consent, the involvement of parents/ carers/partner, school counsellors/teachers may assist in identifying possible causes of the young person s distress and providing information about any changes in his or her behaviour or functioning. A diagnosis of major depressive disorder is based on clinical judgement, including consideration of the young person s level of impairment and whether symptoms are consistent with accepted diagnostic criteria. 1 of 4

6 Assessing depressive symptoms in young people Characterisation of depressive disorders Dysthymia Major depressive disorder Depressed mood or irritability, on most days for most of the day, lasting for at least one year, together with two other symptoms such as: changes in appetite and weight changes in sleep problems with decision-making and concentration low self-esteem, energy and hope. A depressive episode of at least two weeks duration consisting of either sad or irritable mood or anhedonia (loss of the normal pleasure response), together with at least five other symptoms such as: social withdrawal worthlessness guilt suicidal thinking or behaviour sleep increase or decrease decreased motivation or concentration increased or decreased appetite. For a diagnosis of major depressive disorder, these symptoms must cause clinically significant distress or impaired social, occupational or other functioning, represent a change from previous functioning, and must not be attributable to substance use, medication or other psychiatric or medical illness. Bipolar I disorder Bipolar II disorder History of manic or hypomanic episodes. Usually also a history of one or more episodes of major depressive disorder. At least one hypomanic episode and at least one major depressive episode. Depressive episodes are more frequent and more intense than manic episodes. 2 of 4

7 Process of assessment Initial assessment Establish parameters of assessment (e.g. confidentiality) and rapport. Take a history of the presenting difficulties, including onset of symptoms. Investigate context (e.g. current and past medical history, family history, family and parent support and/or conflict, drug and alcohol issues, quality of peer relationships, romantic relationships, and school and/or employment issues); consider use of a psychosocial assessment framework (e.g. HEADSS). Assess mental state (e.g. appearance, behaviour, speech, mood, recent typical thought processes, attention, memory and level of consciousness). Possible depressive symptoms Conduct clinical interview (e.g. assess for presence of symptoms consistent with diagnostic criteria for depression, in line with major international classification systems for depressive conditions (e.g. DSM-IV-TR). Consider use of a validated assessment tool (e.g. Children s Depression Inventory, Reynolds Adolescent Depression Scale). Depressive symptoms present Assess risk of suicide and manage any immediate risk (see Table 1). Assess whether symptoms are attributable to: direct effects of a medical disorder (e.g. infections, endocrine, central nervous system and metabolic disorders) direct effects of a substance (e.g. alcohol use or withdrawal, drug use; certain medications) a non-mood psychiatric condition (e.g. eating disorder, anxiety disorder or post-traumatic stress disorder, Attention deficit-hyperactivity disorder (ADHD), conduct disorder, antisocial behaviour, personality traits) bipolar disorder (e.g. is there a history or symptoms of mania or hypomania) recent experience of loss (in situations of loss, young people may suffer from normal grief, depression, post-traumatic stress reactions or all three). Symptoms not attributable to other causes Assess whether the symptoms meet criteria for major depressive disorder or dysthymia (e.g. DSM-IV-TR). Symptoms do not meet criteria for major depressive disorder or dysthymia Assess whether the symptoms are attributable to an adjustment disorder (consider whether symptoms developed within three months of a stressor, how long they persisted and level of distress and impairment). Symptoms are not attributable to adjustment disorder and are clinically significant Consider a diagnosis of depressive disorder not otherwise specified. Notes: DSM-IV-TR=Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, text revision; HEADSS= Home, Education, Activities, Drugs, Sexuality and Suicide and Depression 3 of 4

8 Table 1 Assessing and responding to risk of suicide ASK Suicidal thoughts Plan Lethality Means Past history Suicide of family member or peer Passing thoughts of self-harm or suicide, but no plan or means Suicidal thoughts and intent, but no plan or immediate means Continual/specific suicidal thoughts, intent, plan and means Low risk Discuss availability of support and treatment options. Arrange follow-up consultation (timing based on clinical judgement). Identify relevant community resources and provide contact details. POSSIBLE risk Discuss availability of support and treatment options. Arrange re-assessment within one week. Develop safety plan with the young person including rapid re-assessment if symptoms escalate. POSSIBLE High risk Ensure young person is in a safe and secure environment. Arrange re-assessment within 24 hours and monitoring for this period. Follow-up outcome of assessment. The information in this fact sheet is derived from the beyondblue (2011) Clinical Practice Guidelines: Depression in adolescents and young adults. Melbourne: beyondblue, the national depression and anxiety initiative. Beyond Blue Ltd Information and help lines beyondblue Info line headspace Black Dog Institute GP Psych Support For urgent assistance contact 000 or relevant local mental health crisis intervention team. 4 of 4

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