Interviewing skills and clinical judgment are required of the clinician in these situations. It is important to:
- obtain a complete description of the adolescent’s behavior and mood over time and as accurate a description as possible of when changes occurred
- assess comorbid conditions (particularly anxiety, attention-deficit/hyperactivity disorder [ADHD], conduct disorder, and substance abuse)
- differentiate between unipolar MDD and bipolar disorder
- evaluate the risk of suicide.
Table 1
DEPRESSION IN ADOLESCENTS AND ADULTS
| Similarities | Differences |
|---|---|
| Same types of diagnostic categories (i.e., major depression, dysthymia, depression NOS) | To diagnose dysthymia, minimum duration of mood disturbance must be 1 year in adolescents (2 years in adults) |
| Same diagnostic symptoms criteria | Mood is often irritable in adolescents (rather than depressed) |
| More common in females | |
| Suicide is more common among males | |
| Evidence of efficacy of SSRI antidepressants | No evidence of efficacy of tricyclic antidepressants in adolescent depression |
Interviewing Standardized diagnostic interviews, such as the Schedule for Affective Disorders and Schizophrenia for children (K-SADS), are commonly used to research adolescent depression but require special training and approximately 1 to 2 hours to administer. As an alternative, clinicians generally develop their own “semi-structured interview” to try to collect all the relevant information required for an accurate diagnosis.7
The interview should be conducted with the adolescent and the parent(s), first separately for ease of disclosure then together to reconcile any differences in the information they report. Open-ended questions and time for building rapport may facilitate disclosure from a reticent adolescent. At times, however, one must make the diagnosis by relying more on reports from others who know the child well. Building a trusting therapeutic relationship then becomes part of ongoing treatment.
Standardized measures In addition to the interview, standardized self-report and other-report measures can help:
- The Child Depression Rating Scale-Revised, commonly used in clinical research, can also be used in practice to quantify symptom severity and document treatment response. A score above 40 usually indicates major depression; a score below 28 indicates remission of depression.8-10
- The Beck Depression Inventory (BDI), a 21-item self-report questionnaire for adults, has reasonable reliability and validity for adolescents. Its modest specificity suggests that it may measure general distress and dysphoria, which is not specific to depressive disorders. The language may be too difficult for some younger adolescents and those with poor reading comprehension skills.
- The Children’s Depression Inventory, a version of the BDI for prepubertal children, can be considered for adolescents whose cognitive and/or reading skills are less mature.
- Achenbach’s Child Behavior Checklists and other standardized questionnaires can screen for comorbid psychopathology.
Assessing psychosocial stress, such as conflicts with parents or peers, school problems, or risk-taking behavior, is also important. Depressed youth often have family members with histories of depression, alcoholism, anxiety, and other psychiatric diagnoses. History of sexual abuse has been linked to depression.3 The depressed adolescent’s impaired functioning in school and at home may cause secondary stress, increasing the burden of illness and need for treatment.
Suicide risk Although suicide remains rare among adolescents in general, the rate of suicide among this age group has risen dramatically over the past decade, particularly among younger teens and preteens. In 1997, suicide was the third leading cause of death in adolescents after accidental injuries and homicide.
Adolescents with depressive disorders are at increased risk for suicide, and boys are more likely than girls to attempt and complete suicide. It is therefore imperative to assess and document suicide risk for each adolescent who presents with depressive symptoms.
After establishing a rapport, the most effective screening is a straightforward conversation with the adolescent about suicidal ideation, intent, and behavior. Assess the social context of support and psychopathology in the family, availability and accessibility of lethal suicide methods (e.g., firearms in the home), and presence of events that could influence imitative suicidal behavior (e.g., a friend’s suicide).6
Treatment
Approaches to adolescent depression include (in increasing order of intensity and complexity) watchful monitoring, nonspecific supportive therapy, pharmacotherapy, specific psychotherapy (i.e., cognitive-behavioral or interpersonal therapy), and combined treatment (e.g., psychotherapy plus pharmacotherapy, adolescent psychotherapy plus family therapy).
There are no clear-cut guidelines as to whether pharmacologic or psychosocial therapy should be offered first.11 In the community, patient and family preferences, past treatment response, and the clinician’s background and expertise influence the choice of treatment. As with adults, adolescents deemed at high risk for suicidal behavior must receive immediate attention from mental health professionals and must be monitored, usually in an inpatient setting.
Watchful monitoring means to wait and see if the youth improves spontaneously.
In some studies, nearly one-half (48%) of adolescents with depression were found to go into spontaneous remission within 8 weeks.12 Watchful monitoring, however, would leave most patients still depressed, and no predictors of spontaneous remission have been identified.