The treatment of youth depression has become increasingly specialised and is now recognised as distinct from adult and paediatric treatment models. Adolescence and young adulthood are characterised by rapid physical, cognitive and psychosocial changes, and form not only the peak period for the emergence of mood disorders (Jaffe et al., 2002), but also herald a window of opportunity for early intervention and prevention of long-term negative psychosocial impact and functional impairment. Though supporting data remain scarce, effective treatment of youth depression may assist to decrease relapse or recurrence in later life (Treatment for Adolescents with Depression Study, 2009). This article outlines the formulation-based assessment and early intervention multimodal treatment model used by clinicians in the Youth Mood Clinic at Orygen Youth Health when working with adolescents and young adults experiencing moderate-to-severe major depressive disorder.
Identification and engagement
A number of specific approaches have been identified in assessing and treating depression in young people, and practitioners are encouraged to familiarise themselves with the beyondblue (2010) Clinical Practice Guidelines: Depression in Adolescents and Young Adults. While in general depressive symptoms are similar in young people compared to older adults, younger adolescents may be more likely to present with irritability, anger and somatic complaints rather than depressed mood, hopelessness and despair (Verduyn, 2011). Young people may also present primarily with other concerns such as substance misuse, eating problems and academic difficulties, all of which may be underpinned by problems with their mood.
Strategies that facilitate greater access to treatment include flexible hours for appointments, youth-friendly reading material in the waiting room, and text message appointment reminders. Appropriate follow-up of non-attendance should be made without the clinician being overbearing or controlling, leaving open the possibility of future treatment engagement. Defining the therapeutic contract, identifying problems from the young person’s point of view (being sensitive to their vocabulary), collaborative goal setting, and shared decision making and formulation enable clients and clinicians to come to a mutual understanding of the young person’s difficulties (see Verduyn, 2011).
It is important to speak directly to young people and not just to their care-givers; this should begin from the first assessment session, where the clinician interviews the young person alone, and then with the care-giver later in the session or at a subsequent session. Other engagement tips include avoiding the use of jargon, utilising humour where appropriate, and validating attendance and effort. Issues of stigma, stoicism and poor mental health literacy may also impede engagement, especially for young males. This may be circumvented by taking time to establish rapport, normalising depression as a common illness that has both biological and social components, emphasising the high likelihood of favourable treatment outcome and improved quality of life with regular attendance, and linking young people with online peer and professional support communities such as the e-headspace online mental health project (for further engagement tips for working with young people see McCutcheon, Chanen, Fraser, Drew, & Brewer, 2007). Degree of input and involvement with family members should be negotiated early in treatment, and relevant ethical and confidentiality issues (including limits to confidentiality) should be considered in the context of the mature minor principle.
Concrete behavioural strategies may be needed for earlier adolescents, whereas older adolescents and young adults may be better able to utilise cognitive interventions (Hollon, Garber, & Shelton, 2005). In addition to supportive counselling, simple interventions for mild depressive presentations for younger clients may focus primarily on behavioural factors, including behavioural activation, mood monitoring, chain analysis, development of problem solving skills, and encouraging activities that promote competence.
In addition to this, for moderate to severe depression cognitive behavioural therapy may be used to identify, challenge and restructure maladaptive automatic thoughts, problematic core beliefs and unhelpful thinking styles. As required, treatment may also focus on managing social anxiety or anger (see Youth Mood Clinic, 2012). Practitioners may also need to promote client skills in distress tolerance and emotion regulation (including recognition of emotions, relaxation, distraction, acceptance and self-soothing – see McKay, Wood, & Brantley, 2007). Furthermore, elements of interpersonal therapy, focussing on development of communication and social skills, may be useful in assisting young people to establish or re-establish meaningful, supportive and enjoyable peer relationships (beyondblue, 2010). In addition, family therapy may also be indicated, and in such cases practitioners need to be mindful of balancing family sessions with young people’s increased independence and separation from family.
Pharmacotherapy and liaison with medical practitioners
The use of antidepressant medication with young people remains contentious, though there is evidence of modest effectiveness, especially in combination with therapy (March et al., 2004). Trialling an SSRI (selective serotonin reuptake inhibitor) should only be considered after discussing the relevant risks (Hetrick, McKenzie, & Merry, 2010), and should only occur within the context of an ongoing therapeutic relationship and management plan (beyondblue, 2010). Close monitoring of response to medication by psychiatrists or GPs is critical given the small but real risk of increases in suicidal thoughts and behaviours at commencement of medication (March & Vitiello, 2009). Psychologists should also liaise with medical practitioners regarding safety planning in instances of escalating risk (see boxed information).
|ASSESSMENT OF SUICIDE RISK AND SELF-HARM IN ADOLESCENTS AND YOUNG ADULTS
Clinicians working with adolescents and young adults experiencing depressive disorders must regularly assess risk of suicide and deliberate self-harm (DSH). Responses to DSH or suicidal ideation should not be punitive. Normalising suicidal or self-harm cognitions as common to those experiencing depression may assist in open discussion, assessment and safety planning. Practitioners can use motivational interviewing techniques to evaluate the pros and cons of DSH coping behaviours and seek to introduce alternative distress management techniques (see McKay, Wood, & Brantley, 2007). Clients should be provided with psychoeducation regarding causes and precipitants of self-harming behaviours and discussion of risks related to wound infection and management, and risk of accidental death by underestimating lethality of overdose (see McCutcheon, Chanen, Fraser, Drew, & Brewer, 2007).
In instances of suicidal ideation and high suicide risk changeability, clinicians may integrate information from risk history and corroborative information provided by others to guide clinical decision making. Consideration should be given to broader psychosocial risk and protective factors, ‘at risk’ mental states, and assessment confidence, and be reassessed regularly, especially in instances of high-risk changeability (see O’Connor, Warby, Raphael, & Vassallo, 2004). Cases of serious concern and high risk will need to be referred to local child mental health or crisis assessment services for crisis follow up.
Psychosocial and vocational planning
As increased academic or vocational stress can precipitate depressive symptoms, which can in turn negatively impact academic or work performance, liaison with a young person’s school (or in some circumstances, employer) may be a vital part of treatment. With appropriate consent from the client, practitioners may need to inform school welfare coordinators of progress, risk and safety planning, and modification of school tasks as required. Fostering collaborative relationships with staff at local schools will assist this process. To facilitate ongoing functional gains, planning for termination of therapy and relevant referral to local educational and vocational support services should be undertaken early in treatment wherever possible. Finally, sufficient attention should be given to relapse prevention and wellness planning specifically relevant to young people.
Practitioners are encouraged to be mindful of the developmental challenges and changes inherent in working with mood disorders in young people. Treatment approaches that meet clients where ‘they are at’ developmentally and psychosocially will optimise engagement and therapeutic outcomes, and increase the likelihood of functional recovery.
The authors wish to acknowledge clinicians, past and present, of the Youth Mood Clinic at Orygen Youth Health for providing input into the development of this treatment model. The authors also thank Louise McCutcheon for providing resources on management of risk in young people.
The principal author can be contacted at Simon.Rice@mh.org.au
- beyondblue. (2010). Clinical practice guidelines: Depression in adolescents and young adults. Melbourne: beyondblue.
- Hetrick, S., McKenzie, J., & Merry, S. (2010). The use of SSRIs in children and adolescents. Current Opinion in Psychiatry, 23, 53-57.
- Hollon, S.D., Garber, J., Shelton, R.C. (2005). Treatment of depression in adolescents with cognitive behavior therapy and medications: a commentary on the TADS project. Cognitive and Behavioral Practice, 12, 149-155.
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- March, J., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J. et al. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 292(7), 807-820.
- March, J. S. & Vitiello, B. (2009). Clinical messages from the Treatment for Adolescents with Depression Study (TADS). The American Journal of Psychiatry, 166, 1118-1123.
- McCutcheon, L., Chanen, A., Fraser, R., Drew, L., & Brewer, W. (2007). Tips and techniques for engaging and managing the reluctant, resistant or hostile young person. Medical Journal of Australia, 187, S64-S67.
- McKay, M., Wood, J.C., & Brantley, J.B. (2007). The dialectical behavior therapy skills workbook. Oakland CA: New Harbinger Publications.
- O’Connor, N., Warby, M., Raphael, B., & Vassallo, T. (2004). Changeability, confidence, common sense and corroboration: Comprehensive suicide risk assessment. Australasian Psychiatry, 12, 352-360.
- Treatment for Adolescents with Depression Study. (2009). The Treatment for Adolescents with Depression Study (TADS): Outcomes over 1 year of naturalistic follow-up. American Journal of Psychiatry, 166, 1141-1149.
- Verduyn, C. (2011). Cognitive-behavioral therapy for depression in children and adolescents. Tidsskrift for Norsk Psykologforening, 48, 34-39.
- Youth Mood Clinic. (2012). CBT for Youth Depression: A treatment manual. Melbourne: Orygen Youth Health.