6.15am and I'm sitting in front of my computer. Berg's violin concerto is playing on Radio 3 (it's through their "listen again" feature). This seems appropriate as the work is dedicated "To the memory of an angel". The "angel" was a teenager, Manon Gropius. Paralysed by polio at age 17, Manon died the next year. Unhappy and sometimes tragic teenagers - yesterday I read the fine review article by Dubicka and Wilkinson published in December's Evidence-Based Mental Health (EBMH). EBMH describes itself as "A quarterly digest of the most important clinical research of relevance to clinicians in mental health" and it pretty much provides what's written on the box. Unfortunately even an online-only personal subscription currently costs £54 (plus tax) annually.

The article is good, sobering, enlightening. If you're a health professional, looking at this blog, who works a good deal with adolescents suffering from depression, then this paper is worth getting hold of and reading in full. Even if your work/experience/interest isn't as a health worker in the field, you may still want to read this helpful overview of the current situation in this area. If you follow the "Full Text" link at the end of this posting, it should get you to the article. If you don't qualify to get it for free, you could always try writing to the corresponding author Dr B Dubicka via
Bernadka.Dubicka@manchester.ac.uk to ask if she would be kind enough to email you a PDF of it.

Dubicka and Wilkinson start by pointing out "Adolescent depression is a serious and debilitating disorder. Up to one in 20 adolescents suffer from major depression at any point in time, and 20% of adolescents have at least one episode of clinical depression by the age of 18. Once depression is established it often becomes chronic. About a fifth of adolescents with major depression will continue to have a persistent disorder, and another third will recover but go on to have recurrent episodes"

It's a very sobering introduction to their article. They go on to talk about the 6 "C's" of depression - Common, Chronic, Causation complex, Comorbidity, Complications, and Commit suicide. Happily they are not suggesting that all six "C's" are going to be involved for all adolescent depression sufferers. They are suggesting though that one should keep all six of these aspects in mind. Common - this is covered in their introductory paragraph (see above), as is Chronic. Causation complex - genetic factors, upbringing, school experience, life events, coping style - a whole raft of different interweaving facets can be relevant. I quite often show people my "Development & maintenance of distressed states" diagram as it helps to illustrate some of these issues. Comorbidity - this is often not well appreciated. Goodyer and colleagues point out, in their important treatment study (Goodyer, Dubicka et al. 2007) involving 208 adolescents with moderate to severe major depression, that 89% suffered from a comorbid disorder, with the average number of additional disorders being three. The six commonest comorbid disorders (in order) were social anxiety disorder, obsessive compulsive disorder, posttraumatic stress disorder, agoraphobia, separation anxiety disorder, and specific phobia.

In the EBMH article, the authors point out that in addition to Comorbidity, Complications include school refusal, academic failure, impaired peer relations, drug and alcohol abuse, and family relationship problems. The sixth of their 6 "C's" is Commit suicide. Depression is the most important risk factor for suicidality. Findings from 20-year follow-up data of depressed children and adolescents have shown that 2.5% had committed suicide and nearly half had attempted suicide (Hazell 2007).

The evidence for CBT is conflicting, but it probably has a role in mild depression and for adolescents who refuse medication. There is some evidence to suggest that CBT may be more beneficial in high income families and for high levels of cognitive distortions. CBT is a scarce and expensive resource which therefore needs to be targeted at those who may benefit most. Interpersonal psychotherapy appears to be a promising treatment as is behavioural activation, but more training and research is needed in these areas. In moderate to severe depression, the greatest evidence for efficacy (compared with both placebo and CBT) has been demonstrated for fluoxetine. This should therefore be offered early in treatment, with an explanation of the evidence base and possible risk of suicidality with antidepressants, versus the known risk of suicide in depression, so families can make an informed decision regarding the possible risks and benefits of both medication and psychological treatment. However, ADAPT findings suggest that a non-specific brief psychosocial intervention may be helpful in some cases prior to initiating a more specialised treatment, and this requires further investigation. In light of recent evidence, the current UK NICE guidelines need revising. In the future we need improved trial methodology which reflects typical clinical populations, an improved understanding of phenomenology, and more effective targeted treatments, which take account of the heterogeneity found in adolescent depression.

Dubicka, B. and P. Wilkinson (2007). "Evidence-based treatment of adolescent major depression." Evid Based Ment Health 10(4): 100-102. [Full Text] [PubMed]
Evidence Based Mental Health. http://ebmh.bmj.com/ Accessed January 16, 2008.
Goodyer, I., B. Dubicka, et al. (2007). "Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial." Bmj 335(7611): 142. [Free Full Text]
Hazell, P. (2007). "Depression in adolescents." Bmj 335(7611): 106-7. [Full Text]