Clinical Context

Although depression is often thought of primarily as a diagnosis of adults, the authors of the current review note that more than 40% of people with depression have symptoms before adulthood. The prevalence of major depressive disorder (MDD) among adolescents was 13% to 15% before the COVID-19 pandemic, but newer research has found that approximately 25% of adolescents had symptoms of depression during the pandemic. Depression was particularly more common during the pandemic among older adolescents and females.

There is no direct evidence that screening for depression among adolescents in primary care improves patient outcomes. However, indirect evidence suggests that treatment of MDD detected by screening is associated with a moderate benefit for the patient. National recommendations in the US and Canada recommend screening for depression among adolescents, and the authors of the current review recommend the Patient Health Questionnaire-9 (PHQ-9), PHQ modified for adolescents (PHQ-A), or Center for Epidemiologic Studies Depression Scale for Children for screening for depression. However, before assessment, clinicians should review confidentiality and its limitations with adolescent patients.

The authors of the current review also provide recommendations regarding the diagnosis and management of depression among adolescents. These themes are summarized in “Study Highlights.”

Study Synopsis and Perspective

A new review drafted by 3 Canadian psychiatrists aims to help primary care physicians diagnose and manage depression in adolescents.

Depression is common among Canadian adolescents and often goes unnoticed. Many family physicians report feeling unprepared to identify and manage depression in these patients.

“Depression is an increasingly common but treatable condition among adolescents,” the authors write. “Primary care physicians and pediatricians are well positioned to support the assessment and first-line management of depression in this group, helping patients to regain their health and function.”

The article was published May 29 in CMAJ.

Distinct Presentation

More than 40% of cases of depression begin during childhood. Onset at this life stage is associated with worse severity of depression in adulthood and worse social, occupational, and physical health outcomes.

Depression is influenced by genetic and environmental factors. Family history of depression is associated with a 3- to 5-fold increased risk for depression among older children. Genetic loci are known to be associated with depression, but exposure to parental depression, adverse childhood experiences, and family conflict are also linked to greater risk. Bullying and stigma are associated with greater risk among lesbian, gay, bisexual, and transgender youth.

Compared with adults, adolescents with depression are more likely to be irritable and to have a labile mood, rather than a low mood. Social withdrawal is also more common among adolescents than among adults. Unusual features, such as hypersomnia and increased appetite, may also be present. Anxiety, somatic symptoms, psychomotor agitation, and hallucinations are more common in adolescents than in younger persons with depression. It is vital to assess risk for suicidality and self-injury, as well as support systems, and validated scales such as the Columbia Suicide Severity Rating Scale can be useful.

There is no consensus as to whether universal screening for depression is beneficial among adolescents. “Screening in this age group may be a reasonable approach, however, when implemented together with adequate systems that ensure accurate diagnosis and appropriate follow-up,” write the authors.

Management of depression in adolescents should begin with psychoeducation and may include lifestyle modification, psychotherapy, and medication. “Importantly, a suicide risk assessment must be done to ensure appropriateness of an outpatient management plan and facilitate safety planning,” the authors write.

Lifestyle interventions may target physical activity, diet, and sleep, as unhealthy patterns in all 3 are associated with heightened symptoms of depression in this population. Regular moderate to vigorous physical activity, and perhaps physical activity of short duration, can improve mood in adolescents. Reduced consumption of sugar-sweetened drinks, processed foods, and meats, along with greater consumption of fruits and legumes, has been shown to reduce depressive symptoms in randomized controlled trials with adults.

Among psychotherapeutic approaches, cognitive-behavioral therapy has shown the most evidence of efficacy among adolescents with depression, although it is less effective for those with more severe symptoms, poor coping skills, and nonsuicidal self-injury. Some evidence supports interpersonal therapy, which focuses on relationships and social functioning. The involvement of caregivers may improve the response compared with psychotherapy that only includes the adolescent.

The authors recommend antidepressant medications in more severe cases or when psychotherapy is ineffective or impossible. Guidelines generally support trials with at least 2 selective serotonin reuptake inhibitors before switching to another drug class, as efficacy data for them are sparser and other drugs have worse adverse effect profiles.

About 2% of adolescents with depression experience an increase in suicidal ideation and behavior after exposure to antidepressants, usually within the first weeks of initiation, so this potential risk should be discussed with patients and caregivers.

Clinicians Feel Unprepared

Commenting on the review for Medscape Medical News, Pierre-Paul Tellier, MD, an associate professor of family medicine at McGill University in Montreal, Canada, said that clinicians frequently report that they do not feel confident in their ability to manage and diagnose adolescent depression. “We did 2 systematic reviews to look at the continuing professional development of family physicians in adolescent health, and it turned out that there’s really a very large lack. When we looked at residents and the training that they were getting in adolescent medicine, it was very similar, so they felt unprepared to deal with issues around mental health.”

Medication can be effective, but it can be seen as “an easy way out,” Dr Tellier added. “It’s not necessarily an ideal plan. What we need to do is to change the person’s way of thinking, the person’s way of responding to a variety of things which will occur throughout their lives. People will have other transition periods in their lives. It’s best if they learn a variety of techniques to deal with depression.”

These techniques include exercise, relaxation methods (which reduce anxiety), and wellness training. Through such techniques, patients “learn a healthier way of living with themselves and who they are, and then this is a lifelong way of learning,” said Dr Tellier. “If I give you a pill, what I’m teaching is, yes, you can feel better. But you’re not dealing with the problem, you’re just dealing with the symptoms.”

He frequently refers his patients to videos that outline and explain various strategies. A favorite is a deep breathing exercise presented by Jeremy Howick.

The authors and Tellier have disclosed no relevant financial relationships.

CMAJ. 2023;195(21):E739-E746.^[1]

Implications for the healthcare team:

• The diagnosis of MDD among adolescents requires at least 2 weeks of symptoms that go beyond depressed mood or anhedonia. Hypersomnia and increased appetite are more prevalent among adolescents vs adults with MDD. Workup for potential depression should include a complete blood count and assessment of thyroid function, but further testing is usually not warranted.
• Cognitive behavioral therapy is a first-line treatment option for depression among adolescents. If using medication therapy, adolescents should complete trials with at least 2 SSRIs before trying other classes of antidepressants.
• The prevalence of depression among adolescents increased during the COVID-19 pandemic. Clinicians should screen adolescents for depression and recommend guideline-based therapy when appropriate.

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