Résumé

(French Language)

Le traitement de la dépression chez les adolescents comporte de multiples modalités, incluant des interventions de nature pharmacologique, psychothérapeutique, éducative et familiale. Les médicaments ont un rôle limité: leur efficacité est minimale, ils n’influencent pas les facteurs étiologiques et l’inobservance est un problème fréquent chez les adolescents. Les médecins devraient plutôt insister sur les mécanismes d’adaptation et les modalités efficaces de solution de problème pour prévenir la récurrence de la dépression.

In contrast to the treatment of depression in adults, medication has a limited role for treating adolescent depression. There are several reasons for this. First is the lack of efficacy (as described below) and second is the limited effect of medications on etiological factors. Because many risk factors, such as anxiety, and developmental and learning problems persist, they must be addressed specifically because they perpetuate the depression.

Third, adolescents are likely to be noncompliant with medication. They struggle with the idea of taking mood-altering substances recommended by adults while they are developing an independent identity and are subject to peer pressure. Adolescents have commented that taking pills proves to them that they are “psycho.” Finally, those adolescents who have developed clinical depression really need coping mechanisms and effective problem-solving styles in order to help repair the damaging effects of the depression and to prevent its recurrence.

Comprehensive approach

The principles for treating adolescent depression are:
• ensure confidentiality,
• establish rapport,
• assess suicide risk,
• involve the family, and
• maintain school supports.

Adolescents can rarely be treated successfully without the active support of the family and school. The teen’s academic load might need to be adapted, specific learning difficulties remediated, and school counseling provided to prevent development of school avoidance behaviour. The family’s inevitable frustration and criticism of the depressed teen’s “laziness” needs to be changed, and other contributing environmental factors addressed.

The comprehensive approach to adolescent depression includes some common sense measures, such as sleep hygiene, regular meals, exercise, time management, and combating social withdrawal. The immobilized, overwhelmed teen needs help with setting priorities to combat helplessness and hopelessness. A support system of caring adults and peers who will not simply give advice but will promote strengths and problem-solving is crucial. Depressed individuals need to take control of their lives because this is the antidote to hopelessness. Social skills and assertiveness training, stress management, and cognitive-behavioural strategies are among the more specialized tools that will benefit depressed adolescents.

Secondary prevention is an important aspect of the comprehensive approach. Risk reduction and improved coping strategies help to deal with factors that are often persistent. Understanding the role of these etiologic factors is critical for treating each individual case. For example, a young person with a strong family history of depression, who is at high genetic risk and who has had previous major depressive episodes, needs to be alerted to early symptoms of recurrence and taught preventive strategies and coping mechanisms to use while an active biological approach to treatment and maintenance therapy is instituted. On the other hand, an adolescent with a weak family history of depression and a strong history of developmental problems or psychosocial stressors will require a primarily psychotherapeutic and behavioural approach to prevent recurrence.

Managing suicidal thoughts. Adolescents are at special risk for suicidal behaviour. Follow-up studies have shown that depressed adolescents are at very high risk. One study showed that the most common method of completing suicide was tricyclic antidepressant overdose. While younger children have suicidal thoughts in the context of depression, they more rarely act upon them, perhaps because they lack the ability to formulate and carry out a plan. However, age of first suicidal behaviour might be declining, likely due to children’s greater awareness of potential methods, especially overdosing on nonprescription medications. Suicidal thoughts arise from a sense of hopelessness and isolation. The first step in preventing suicidal behaviour in a depressed adolescent is to develop rapport and a therapeutic relationship in which isolation is reduced and hopelessness combated by the more optimistic view of a physician or other professional. Emergency telephone numbers, crisis lines, or the ready response of a family physician or counselor are especially important for this age group. Adolescents will rarely abuse a 24-hour phone line to a physician, and this could be lifesaving.

Role of family therapy. In some cases, a depressed adolescent is the symptom of a family problem, and treatment could be ineffective if the problem is not identified at its source. An example is a severely depressed 15-year-old who was resistant to psychotherapy and pharmacotherapy with full trials of two serotonergic reuptake inhibitors and a tricyclic antidepressant, failed to improve with psychiatric hospitalization, and remained functionally impaired and suicidal. During a second hospitalization, the family secret came to light. Mother had a long-standing affair with another man who was in the role of substitute father for the children but needed to be concealed from their biological father. Chronic but unacknowledged marital conflict was fueling the hopelessness and helplessness of this bright teen. She felt responsible but paralyzed and was very much caught between the parents. Her depression finally began to resolve, without any medication, as the family faced the situation directly. Adolescents most vulnerable to developing “symptomatic” depression are those who are introverted, anxious, and conscientious, often excessively enmeshed in their parents’ problems and taking precocious responsibility for the well-being of the adults in the family. Parental depression or other serious psychiatric disorders, substance abuse, and covert marital problems are examples of the kinds of family problems an adolescent might be masking. Indeed, the adolescent’s symptoms could be the one factor uniting parents whose marriage is about to dissolve. A family therapy approach might be resisted by parents and siblings who have conspired to keep family secrets hidden. If a family physician is pressured to accept this conspiracy of silence, the outcome for the depressed adolescent is then poor.

Resources for nonpharmacologic interventions. The time-consuming work of nonpharmacologic intervention can be shared. Family physicians can draw upon many skilled community resources, such as school counselors, mental health centre’s, family services and social agencies, alcohol and drug programs, psychiatrists, psychologists, social workers, and other trained family therapists. It is crucial, however, that these agencies communicate with primary physicians and that all of the therapeutic interventions are integrated rather than contradictory. A safety net is created by parents, schools, physicians, and other agencies operating together on behalf of a depressed adolescent. Conflicting approaches and disagreement among the family, school, and various other professionals will only increase an adolescent’s sense of isolation and discouragement.

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