As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And depressed teenagers who are usually high achievers still may be functioning adequately, although at a much lower level than usual.
When you have diagnosed depression, treatment starts when you describe it as an illness, not a character flaw. Although there is less stigma around mental illness now than there was in the past, depression can create feelings of guilt and worthlessness, to which insecure adolescents may be particularly vulnerable. Hearing from a trusted physician that these feelings are symptoms, not facts, can be powerfully protective.
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Sleep often is disrupted in depression, and sleep deprivation (not uncommon in adolescence) can further impair attention and concentration and worsen anxiety and depressive symptoms. Teach your depressed patient and their parents about the critical importance of protecting their sleep with a consistent sleep ritual, limited evening screen time, and avoidance of daytime naps. Exercise not only promotes healthy sleep but has been shown to be as effective as antidepressants in treating mild to moderate episodes of depression. Strategize with your patient to create a realistic plan to get 20 minutes of exercise three times weekly, which can increase as they feel better.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
The black box warning on antidepressants has made many pediatricians want to refer all of their patients to psychiatrists for medication management. How much a pediatrician is willing to manage is a matter of interest, access, and clinical judgment. Sometimes your clinical intuition will dictate if you should refer or try and treat yourself. Beyond your inner sense, we can offer some guidelines. If you have been through two antidepressant trials without substantial improvement or had improvement that subsequently faded, it may be valuable to refer to a psychiatrist. If your patient has symptoms that suggest a more chronic or severe psychiatric illness (such as bipolar disorder or emerging schizophrenia), it is appropriate to refer them to a psychiatrist. If your patient has a comorbid substance abuse problem or eating disorder, it is critical that they get appropriate treatment for that with a referral to an appropriate program. For patients who are suffering from chronic suicidality, impulsive self-injury, and stormy interpersonal relationships alongside their mood symptoms, a referral to a psychiatrist, preferably with experience in dialectical behavioral therapy, is warranted. If your patient has a personal or family history of suicide attempts, it would be reasonable to have their treatment managed by a psychiatrist.
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
