How to prevent teenage depression?

Hannah -   Next, teenage behaviour can have its ups and its downs.  And it's not really surprising, given all the brain changes that occur in the adolescent years, but at what point do the lows become clinical depression?  With suicide the leading cause of teenage death after car accidents, how best to diagnose and treat depression in these years and can the teenage brain ever fully recover in adulthood?  Kate Lamble met up with Dr. Lesley Cousins from Cambridge University to find out.

Lesley -   Estimates vary, but probably around 5% to 6% of adolescents have moderate to severe depression.  Interestingly, the incidents increases as you go through adolescence.  So something is happening in your teenage years which seems to make you susceptible to the risk of becoming depressed.

Kate -   And so, if a teenager says to his mum that they've got depression, what normally happens?  Is there talking therapies or is there a drug response?  What's the normal response?

Lesley -   I think it depends and I think it depends how that young person presents.  I think there's very few teenagers that stand up and say, "Mum, Dad, I think I'm depressed."  And for moderate to severe depression, the treatments are talking therapies and anti-depressants.

Kate -   So, these anti-depressant drugs, if we've given them to someone, a teenager with the developing brain, sort of there's something going on in their brain, have we tested those drugs on teenagers or are they tested on an adult audience?

Lesley -   I think that's a really good point to make.  There's two periods in your life where you have this rate of brain development when you're a baby toddler and then in your teenage years.  So, your brain is changing markedly in this time.  there's two answers to your question.  One is, you're asking if you tested these medications on teenagers and yes, we have in this instant.  We know that they are a relatively effective treatment for depression.  For about 5% to 6%, they help.  We don't really know what antidepressants are doing generally to adult brains or adolescent brains.  A decade ago, there was some concerned raised that antidepressants might be associated with increase in suicidal thoughts in depressed teens.  That led to a real drop in prescribing rates.  Worryingly, what that then led to was an increase in suicide and suicidal attempts in young people.  Although there was a possibility that there's a slight risk in treating young people, what we know is the biggest risk is not treating young people.  Having a depressive episode in your teenage years is absolutely catastrophic.  So, your teenage years are when you lay down the foundations for the rest of your life.  that's where you achieve it.  academically, that's where you learn how to develop and maintain relationships.  So, if you have 6 months depressive illness when you're 15 and doing your GCSEs, that has an entirely different catastrophic consequences than if you have a depressive illness say, maybe for 6 months when you're 30.

Kate -   So, how in particular are you looking at this problem?

Lesley -   Really, I was asking the question of, do we, prescribers were supposed to.  As clinicians, we get guidelines on how to prescribe antidepressants and these guidelines are laid down by NICE.  The NICE guidelines for child and adolescent depression state that you shouldn't give antidepressants until somebody has had their talking therapy.  So, until they've had a field course of talking therapy and then you should give antidepressants based on the severity of depression.  So, the more symptoms you have, the more likely you should be prescribing.  And really, my question was, is this what we're doing?  The answer is, no, we're not.  What we're doing is we're prescribing before people have talking therapy and I think I probably agree with that actually.  talking therapy is very difficult to access.  What the results that I'm presenting show is that instead of presenting for severity of depression for girls who present for risk, who present for risky behaviour, self-harm, and suicidality.  And the worry with that is that we don't have an evidence base for that kind of prescribing.

Kate -   I've heard from acquaintances who have been on antidepressants that they can make you feel in a very different way.  They can make you feel sort of muggy or unable to access feelings.  If we're prescribing those kind of drugs before talking therapies, could that affect the impact and the effectiveness of those talking therapies if they're met, having that sort of emotional reaction to them?

Lesley -   It's a good question and it's probably fair to say that yeah, antidepressants do affect how you're thinking, how you act.  But I think actually, evidence suggests the opposite from what you're suggesting.  So actually, if you're really depressed, managing talking therapies is really difficult.  Managing to discuss your feelings when you're depressed is hard.  So actually, I think antidepressants can help people reach a level in their mood and their cognitive function that allow them to make the most talking therapies.

Kate -   So, if you're concerned about this danger of the lack of evidence base when you're prescribing for girls based on risk factors, what's the danger there?  What could we do?  Are we prescribing too many or are we letting risky factors go by?

Lesley -   I think the danger is we don't quite know what we're doing.  So, psychiatrists working towards being a scientific and robust as it can be.  And like I say, we have good evidence that antidepressants work in moderate and severe depression.  These are the young people that's got to have the most impact.  The grip of people who are risky, self-harming, I understand a clinician's need to act and feel the need to act, but we don't necessarily know that these treatments are going to be so effective in these young people if we're prescribing these in that rationale.

Kate -   So, what's the next step with your research?  Is it to get that evidence base for those girls with risky behaviour and whether those drugs are effective?

Lesley -   All research just leads to more questions and the question for me is, what is it about girls that risk scares us but not depressive symptoms?  Why are we treating boys and girls differently?  Because we shouldn't be.  Is it perhaps that as clinicians, we are used to seeing crying girls in our consultant rooms and we're possibly immune to that.  it takes a sort of elevated level of action for us to pick up our prescribing pads whereas we're not so used to seeing crying boys and that's enough for us to prescribe.

Kate -   So, you might be so used to girls in sessions when they're upset or showing depressive symptoms when they're crying that that doesn't act as an alert signal.  But if a boy does that, that would act as - that's signal enough for you to get out prescription pad and give them something, a treatment.

Lesley -   Possibly.  Who knows?  And I think what this highlights is the complexities that underlie prescribing and the agendas and preconceived ideas consciously and subconsciously that a condition has that they take into the consulting room that affects the conversations that they have and the decisions that they make.

Hannah -   Lesley Cousins, presenting her work, showing that if you're a teenager with depression, whether or not you're prescribed antidepressants seems to be based on which county you live in and your gender rather than the severity of your symptoms, highlighting the requirements for more objective methods for diagnosing and helping to treat depression. 

Well rather timely, in the news this week, the first blood test to help diagnose major depression in adults has been developed by Professor Eva Redei and her team at Northwestern University.  Published in Translational Psychiatry, the test also predicts who will benefit from cognitive behavioural talking therapy.  The study did look at just 32 depressive patients but if the results hold true in larger scale studies, there might be a blood test for depression as there is for high cholesterol, thyroid problems or HIV.