Depression is one of the most common mental health problems in young people worldwide, but it often goes unrecognised and untreated. Left untreated, adolescent depression increases the risk of suicide, substance abuse, and obesity, leads to serious social and educational problems, and can result in lifelong health problems. Although effective treatments are available, the lack of interventions and resources directed to tackling and preventing depression in non-specialist settings (eg, schools, communities, health-care settings) in many countries is a serious concern, concludes a review of the evidence published Online First in The Lancet.
"In view of the disability associated with depression in adolescents, much more needs to be done to recognise and treat those with depression early and to develop innovative and cost-effective methods to improve access and deliver prevention programmes to a far wider group of adolescents particularly in non-specialist settings and in low-income and middle-income countries where the burden is greatest"*, urges Anita Thapar from Cardiff University, Cardiff, UK, lead author of the Seminar.
In any given year, an estimated 4% to 5% of adolescents have depression, and the condition is twice as common in girls as it is in boys. Most young people with depression are vulnerable to recurrent episodes and two-thirds also have another psychiatric disorder or problems with school performance, behaviour, and substance misuse.
Professionals caring for young people in non-specialist settings (eg, health-care settings, schools, and communities) need to be made aware of the possibility of this diagnosis, explain Thapar and colleagues.
"Longitudinal studies of adolescents with sub-syndromal depression [high levels of symptoms but not full-blown depression] show that they are at increased risk of later full-blown depressive disorder. Thus, there are important reasons for paying attention to sub-syndromal depression and targeting individuals with these symptoms for prevention, low-risk intervention strategies, and lifestyle changes."
Research indicates that good quality relationships with parents and peers, emotional-regulation capacities, coping mechanisms, and certain thinking patterns could help protect adolescents from developing depression, particularly those at-risk (eg, with a family history of depression or those exposed to chronic adversity such as abuse and bullying).
According to the National Institute of Medicine, prevention strategies targeted at high-risk individuals, rather than universal screening, seem to be the most promising. For example, cognitive behavioural therapy (CBT) that teaches at-risk adolescents to be optimistic in their thinking and problem solving has been shown to lower the rate of depressive symptoms.
Other programmes that use interpersonal therapy (IPT) have also had preventive effects, but at present most countries have a shortage of professionals trained in these therapies.
The authors suggest that although CBT and IPT are not readily available in most non-specialist settings, access could be made easier through counselling programmes in primary care and schools, and through the use of less expensive approaches such as the internet.
Despite the high burden of depression, treatment and early intervention options are much more limited in low-income and middle-income countries where resources are scarce. But a number of interventions have shown promise. For example, IPT delivered to adolescent survivors of war and displacement by trained local community workers significantly improved symptoms of depression in adolescent girls in Uganda.
The authors caution that there needs to be more evidence of when and for whom different types of intervention work best.
They conclude: "Evidence for the long term benefits of psychological treatment or medication to rates of recurrence and for the effectiveness of non-specialist interventions is scarce. There is an urgent need for more public education about adolescent depression, and continued research to understand what the key components of prevention programmes and policies ought to be."*