Therapeutic Identification of Depression in Young People Identification and Treatment Manual The TIDY project The Academic Unit of Child and Adolescent Psychiatry, Imperial College London & Lonsdale Medical Centre L ONSDALE M EDICAL C ENTRE TIDY the PROJECT
RECOGNISING & RESPONDING TO DEPRESSION: AN OVERVIEW We are asking you to screen all young people (aged between 13 and 17 years) who consult you for any reason, for the possible presence of depression. Rationale We know that young people rarely come to see you because of emotional symptoms but many of them may have an underlying psychiatric disorder that is unrecognised and thus untreated. About the Manual This manual will guide you through a method of recognising and responding to depression. It will help you change the focus of the consultation and then screen for depression using diagnostic criteria. Suggested screening questions are included but you should feel free to alter the language as appropriate for each young person you see. These questions form the backbone of this guide. We hope they will help the consultation and encourage young people to talk about any difficulties they may have. Contents Therapeutic Identification 2 Treating Depression in Young People 6 Need for referral 11 Reattenders 11 Imperial College London, 2008 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission of Imperial College London. 1
THERAPEUTIC IDENTIFICATION There are seven steps in the process of therapeutic identification of depression in young people 1. Consider stressors 2. Consider seeing the young person alone 3. Ask the Transitional Question 4. Use the General Psychiatric Screening Questions 5. Screen for depression 6. Diagnose depression 7. Treat if depression present 1. Be aware of known stressors You may have known young people and their families over a long period of time. When you see young people in a consultation consider whether you know of any particular stressors that could influence their mood. 2. Consider seeing the young person alone Many young people will feel more comfortable disclosing distress in the absence of parents. This may require sensitive negotiation with parents. Limits of confidentiality should be made explicit to young people. 3. Ask the Transitional Question To change the focus of discussion from physical to psychological symptoms use questions like these: Other than your (physical symptom) how have you been? Sometimes (physical symptom) can get worse if you are worried or stressed. Is there anything in particular bothering you at the moment? 2 4. Use the General Psychiatric Screening Questions To facilitate discussion of psychological issues, ask questions like: Do you have any other difficulties or worries at the moment? Is anything else bothering you? Do you see yourself as mainly a happy person or a sad person?
5. Screen for depression To screen, assess the presence of the Core Symptoms i.e. low mood or irritability Core Symptoms i. Ask about mood Lately, have you been feeling more unhappy or miserable or low than usual? Have you been feeling more moody than usual? Have you been feeling more tearful than usual or crying more than usual? Check frequency and duration: How often do you feel this way? How long does the feeling last? When did you start to feel this way? ii. Ask about irritability Have you been feeling more angry or irritable or fed up than usual? Check frequency and duration: How often do you feel this way? How long does the feeling last? When did you start to feel this way? If either mood or irritability symptoms are present ( 3 hrs three times/week) and persistent (2 weeks or more), score 1 and continue If no core symptoms, stop the screening process and complete the checklist 3
6. To diagnose depression In the presence of core symptoms assess for associated symptoms and impairment Associated symptoms NOTE: Score 1 for each symptom present. Always ask Question 8 I m going to ask you about other changes that you might have noticed whilst you ve been feeling miserable/low/more moody/tearful than usual or angry/irritable/fed up than usual 1. Have you noticed a change in your appetite or weight? (Score for or ) 2. Have you felt tired or lacking in energy? 3. Have you noticed a change in your sleep pattern? For example, has it been hard to get to sleep at night/do you find yourself waking up during the night /are you waking up earlier than normal in the morning? OR Have you been sleeping more than usual? 4. Have you been feeling especially restless e.g. has it been hard to stay in one place or do you feel you have to be constantly on the move? OR Have you been feeling slowed down, as if it takes ages to get anything done? 5. Has it been hard to keep your mind on what you re doing e.g. reading a book, paying attention in school or following a TV programme? 6. Have you been feeling as if you re not enjoying things as much as you used to, like spending time with your friends or that you ve lost interest in things that you used to enjoy? 7. Do you ever feel that you re to blame for things that are not necessarily your fault? 8. I m just wondering how bad things have got Have there ever been times when things felt completely hopeless? Have you had times when things felt so bad that you wished yourself dead? Have you ever had thoughts about harming yourself? Have you ever actually tried to harm yourself? Do you have any thoughts about harming yourself at the moment? Is it just a thought or do you actually have a plan? 4 If two or more answers are positive, ask about impairment If 1 or less are positive stop here (remember to fill in the checklist)
Impairment 1. Has the way you ve been feeling interfered with how you ve been getting on at school? 2. Has the way you ve been feeling affected how you ve been getting on with your parents and family? 3. Has the way you ve been feeling had any effect on your friendships? Diagnosis of depression present if positive for: one core symptom + two associated symptoms + one area of impairment If depression is present please proceed to the treatment. 5
TREATING DEPRESSION IN YOUNG PEOPLE After making a diagnosis 1. Give feedback i Name it ii Describe it i.e. link symptoms iii Link to known stressors iv Give information about depression v Give leaflet 2. Promote coping strategies i Mobilise help / Identify confidante ii Activity Scheduling with Self Reinforcement iii Give positive reinforcement 3. Reminder: It is usually self-limiting 4. Invite back: Remind that further options for help are available 1. Give feedback Rationale Young people may be experiencing depression for the first time. Our clinical impression is that they are often confused and perplexed about what is happening to them. They often do not link the various components or understand the experience as linked to recent stressful experiences. They do not know about depression and are unlikely to communicate with others because of the way they are feeling, resulting in social withdrawal. Therefore, being given a realistic understanding of these factors, may lead to a great sense of relief. Feedback aims to help the young person to understand What they are experiencing i.e. name it Symptoms may be linked as part of a known syndrome Symptoms may be linked with recent stressful experience(s) Depression is a common, self-limiting, treatable although unpleasant, distressing and disabling disorder Feedback steps i Name it What you have just described sounds like you are suffering with mild depression (or a depressive disorder). All people feel down and depressed sometimes, but this is more than just feeling a bit down, because it seems to really have got to you. OR if low mood is not the main feature What you have just described sounds like you are suffering with mild depression (or a depressive disorder). 6
You seem to feel more irritable than sad which is very common in teenagers. OR You seem to feel like you want to withdraw into yourself, which is very common in teenagers. ii Describe it Depression is made up of many of the symptoms/ feelings/ experiences you have described for example. feeling down for a lot of the time being moody and irritable easily upset or tearful difficulty sleeping not enjoying being with your friends seeing life as pointless etc AND it is difficult to carry on as usual ~ keeping up with schoolwork, friends etc Use the young person s words/description, including all symptoms they have reported iii Link it If you are aware of stressors Your worries about exams. Your father s death etc...has put a lot of strain on you and could be making you feel worse If you are not aware of stress Have you had any worries / stresses/ difficulties that could be affecting you? This intervention demonstrates empathy for the young person iv Give information Depression is very common in young people. It is a very difficult and unpleasant experience but there is a lot that can be done to help. It can affect your life in many ways Difficulties getting on with friends and family Losing interest in your friends Difficulty doing school work Difficulty getting up and facing the day.etc The most important thing to remember, however bad you feel is that this happens to a lot of young people and you can get help to get better It will not last forever. v Give leaflet 7
2. Promote coping strategies i Mobilise help / Identify confidante Rationale The anger, irritability, low mood and low self esteem seen with depression may be associated with increased conflict in relationships with friends and family. Also, boredom, inability to enjoy things and social withdrawal may be associated with feeling isolated, alone and uncared for. Friends and family may not understand the changes they see in the young person and are therefore unable to offer support, which reinforces the young person s negative feelings/belief that no-one can help. Aims To help the young person to communicate their distress to someone close in order to enlist their support and understanding. Explain why While you are feeling so depressed/down etc it is very hard for you to communicate with your mother/parents/friends They may not understand why there have been so many arguments.. If they realised how bad you were feeling they may be able to understand/offer support/argue less/nag less..etc OR It sounds like you are stuck in a vicious cycle, the more down and irritable you feel, the more you stay in your room (get upset/ get angry etc), the more you argue with your mother (or friends/don t go out etc) which leaves you feeling even more down (or angry/upset.etc). If your mother (or parents/best friend) realised that it was your depression that was leading to these difficulties, firstly they may be better able to understand what you re going through, and secondly they may be able to help you through it (help avoid arguments.etc). Identify who To help you feel better let s choose one person you could tell about how you have been feeling. Who is one person, just one who you could tell I know this is really difficult but if you could tell just one person If you can t think of anyone now, try and think about it when you get home.. 8 Ask for feedback When I see you again you can let me know how it went.
ii Activity Scheduling with Self Reinforcement Rationale Activity Scheduling Boredom, inactivity and social withdrawal associated with depression lead to exclusion of young people from activities or contacts that are pleasurable, thus reinforcing the young person s negative feelings and thoughts about themselves. Self Reinforcement Depressed young people experience negative thoughts about themselves and may not recognise when they are acting positively. Aims Activity Scheduling To encourage participation in a bit of a pleasurable activity in order to lift mood, decrease withdrawal and increase feelings of coping and mastery. Self Reinforcement To encourage recognition of positive aspects of behaviour, increase feelings of coping and mastery and enable the young person to see positive effects of reward. Methods Activity Scheduling The second thing you could do to help yourself feel better sooner is to reward yourself. Could you do one small thing that you would usually enjoy but haven t been doing so often recently?.. Let the young person select one small but achievable goal: Could include meeting a friend Going out with a friend Going shopping with mother Playing sport Playing their favourite music etc Self Reinforcement Then I am going to ask you to do something which may sound silly at first When you do this extra activity I want you to say to yourself well done.. Remind yourself of your achievement even if it feels difficult to do this. 9
iii Give positive reinforcement Rationale Depressed young people experience negative thoughts about themselves and may not recognise when they are acting positively. Aims To encourage recognition of positive aspects of behaviour To model a positive view of what may seem like a small achievement Methods Identify the positive aspect of the help seeking process. Even though you are feeling so bad/ having such a difficult time, you have managed to come and see me/ tell your mother/tell me. that is a really difficult/brave step and you have done really well. Well done!!! 3. Reminder Remember, it will go away!! 4. Invite back But if it doesn t go away or you would like to talk more please come back and see me again There are other options we could try Now fill out the checklist - THANK YOU! 10
Need for referral When should I consider referral to child and adolescent mental health services (CAMHS)? Taking part in this study should not change your routine care for more severely depressed young people, so follow your usual criteria for referral. Specific features which might indicate the need for CAMHS referral include: The presence of many intense and persistent symptoms of depression (or any psychotic symptoms). Symptoms which currently severely impact on one or more domains of functioning (home, school and friendships) eg not attending school and not going out. Current wish to die or active suicidality. A fleeting wish to die which arises in the context of a conflict and does not persist may not be cause for concern. If the wish is recurrent, persistent or associated with ideas about the means and plans to self harm, referral is required. Inability to identify any confidante or if you are aware that the young person lacks appropriate social support. A young person who seems unable to consider the intervention or to obtain relief from it. Already prescribed (or considering prescription) of an antidepressant. If you are uncertain about whether or not to refer a young person, you could Discuss the situation with the study research assistant. Talk to one of the senior research team we will be glad to offer advice. Reattenders A young person may attend the practice more than once during the study. Some may not have been depressed at the initial consultation; others who were may be following up on your invitation (as part of the treatment intervention) to come back and see you again. What should I do for reattenders? Optimise the context to search for depression (consider seeing the young person alone, use a transitional question to move from physical symptoms to psychological enquiry, be aware of recent stressors) Go through the diagnostic screen for depression again (using the identification tools) Aim to: 1) Determine whether the young person is currently depressed 2) Compare current depressive symptoms with those present at the previous consultation Remember frequent attenders are more likely to have psychiatric disorders 11
Scenario A If the young person wasn t depressed at their first visit but today they are depressed What to do: use the treatment manual Scenario B The young person was depressed at their first visit but they are no longer depressed What to do: 1. Comment on the change in symptoms 2. Identify components of the intervention they have successfully used 3. Give positive reinforcement (i.e. praise) for any effort made How to do it e.g. When I saw you 3 weeks ago you were feeling sad most of the time, feeling tired and could not concentrate at school. You had stopped going to your dancing and singing lessons which you usually enjoyed, you were arguing a lot with your Mum and your grades had dropped at school. It s great to hear that the sadness has almost disappeared now and you re not feeling so tired. You seem very pleased to be back dancing and singing which is great and it s good to hear that you had good marks in your school tests this week and are having fewer arguments with your Mum. Do you remember when we last met I gave you some ideas about things which might help to lift your depression? Which things do you remember? Which did you try?...well done for making that effort. Did the nurse contact you? Did you find that helpful? Scenario C) The young person was depressed at their first visit and they are still depressed What to do: 1. Comment on current symptoms and compare with symptoms at previous consultation 2. Find out which components of the treatment intervention have been used and whether they were helpful 3. Consider whether they need referral (see Need for referral) 4. If not, repeat components of the treatment intervention How to do it e.g. When we met 3 weeks ago you were feeling sad most of the time and crying more than usual. You weren t sleeping well, you weren t feeling hungry and it was hard to pay attention at school. You had stopped texting your friends and going out with them at weekends. It sounds like things haven t changed much since we last met. Do you remember I gave you some ideas about things which might help to lift your depression? Do you remember what those things were? Which things did you try? Did you find it helpful? Has the nurse been in touch with you? How did you find that? I know you said you just couldn t talk to your Mum about how you are feeling but is there anyone else you might be able to talk to? It may seem really difficult but if you can let someone know how you are feeling, they may understand why you have been crying so much and be able to support you. 12
Academic Unit of Child and Adolescent Psychiatry Imperial College London St Mary s Campus Norfolk Place London W2 1PG 020 7886 1145 Lonsdale Medical Centre 24 Lonsdale Road London NW6 6RP 020 7328 6164 L ONSDALE M EDICAL C ENTRE