When should we intervene in adolescent depression and with whom?

Abstract

In a new examination of the Avon Longitudinal Study of Parents and Children, Bryony Weavers and colleagues intricately characterise trajectories of depressive symptoms experienced from adolescence to early adulthood.1Weavers B Heron J Thapar AK et al.The antecedents and outcomes of persistent and remitting adolescent depressive symptom trajectories: a longitudinal, population-based English study.Lancet Psychiatry. 2021; (published online Oct 18.)https://doi.org/10.1016/S2215-0366(21)00281-9Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Examining childhood antecedents of early adult outcomes provides new insight into when we should intervene in adolescent depression, and with whom.The mental health burden and impairment experienced by this cohort of young people accentuate the need for comprehensive sustained services. When symptoms were assessed from age 10–25 years, only a small majority of young people (54%) were found to experience a stable-low risk of clinically significant depression. Almost half (46%) were likely to experience clinically significant depressive symptoms during adolescence or early adulthood.An empirical modelling technique, latent class growth analysis, delineated three patterns of depressive symptoms. First, adolescent-limited symptoms (14%), whereby an inclining risk of clinically significant depression from age 10–18 years had resolved by age 24–25 years. Young people whose symptoms resolved had low rates of functional impairment and high participation in education and employment by age 25 years, with history of suicidal self-harm comparable to the stable-low risk group. By contrast, 7% of young people experienced adolescent-persistent symptoms, characterised by rapidly increasing symptoms over age 10–18 years that persisted into early adulthood. These young adults had the highest rates of functional impairment (62%), non-participation in education, employment, or training (16%), and history of suicidal self-harm (27%). A further 25% of the cohort experienced adult-increasing symptoms, gradually increasing over age 10–25 years and resulting in high rates of functional impairment (42%), non-participation in education, employment, or training (9%), and history of suicidal self-harm (10%).Specialist mental health care services might support only a proportion of these young people, prioritising those with the most severe presentations.2McGorry PD Mei C Early intervention in youth mental health: progress and future directions.Evid Based Ment Health. 2018; 21: 182-184Crossref PubMed Scopus (97) Google Scholar This new population-level evidence calls for urgent examination of routes to extend this support and offer different pathways and ways to overcome the barriers to help-seeking experienced by many young people and their families.3Tylee A Haller DM Graham T Churchill R Sanci LA Youth-friendly primary-care services: how are we doing and what more needs to be done?.Lancet. 2007; 369: 1565-1573Summary Full Text Full Text PDF PubMed Scopus (461) Google Scholar The findings relied on long-term participation, and young men were under-represented. Although analytic correction accounted for cohort attrition, it is likely that many of the young people most impacted by mental health difficulties and social adversity were lost to follow-up or declined participation. Disaggregation of the burden of mental ill-health across social and cultural contexts is urgently needed to advocate equitable responses and ensure provision of culturally appropriate services.4Cook BL Hou SS Lee-Tauler SY Progovac AM Samson F Sanchez MJ A review of mental health and mental health care disparities research: 2011–2014.Med Care Res Rev. 2019; 76: 683-710Crossref PubMed Scopus (44) Google ScholarOften overlooked, a smaller group of younger children (3%) were identified for whom clinically significant depressive symptoms were already prevalent by age 10 years, and were likely to continue into adulthood.1Weavers B Heron J Thapar AK et al.The antecedents and outcomes of persistent and remitting adolescent depressive symptom trajectories: a longitudinal, population-based English study.Lancet Psychiatry. 2021; (published online Oct 18.)https://doi.org/10.1016/S2215-0366(21)00281-9Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Underscoring younger children's experiences, these findings emphasise the need for awareness and recognition of depressive symptoms within paediatric settings.5Hiscock H Mulraney M Efron D et al.Use and predictors of health services among Australian children with mental health problems: a national prospective study.Aust J Psychol. 2020; 72: 31-40Crossref Scopus (9) Google Scholar The long-reaching effects of childhood neurological difficulties, particularly ADHD and traits of autism spectrum disorder, highlight the necessity for integrated services that transition from paediatric to adult mental health care. 6Cleverley K Rowland E Bennett K Jeffs L Gore D Identifying core components and indicators of successful transitions from child to adult mental health services: a scoping review.Eur Child Adolesc Psychiatry. 2020; 29: 107-121Crossref PubMed Scopus (35) Google ScholarLooking beyond depressive symptoms, the study examined childhood antecedents and correlates of symptom trajectories to identify the young people towards whom support might be most effectively directed. Adverse childhood experiences were most common among young people with adolescent-persistent symptoms: the group with the highest number of major depressive episodes, the most significant impact on early adult outcomes, and the highest rates of suicidal self-harm. Recognition of adverse childhood experiences among young people experiencing depressive symptoms draws parallels with complex trauma exposures and responses among young people, accentuating the need for equitable access to trauma-informed and trauma-focused services.7Sweeney A Filson B Kennedy A Collinson L Gillard S A paradigm shift: relationships in trauma-informed mental health services.BJPsych Adv. 2018; 24: 319-333Crossref Scopus (135) Google Scholar The frequent co-occurrence of adverse childhood experiences with social and economic disadvantage highlights the need to address financial, language, and health literacy barriers to accessing mental health support.8Nooteboom LA Mulder EA Kuiper CHZ Colins OF Vermeiren RRJM Towards integrated youth care: a systematic review of facilitators and barriers for professionals.Adm Policy Ment Health. 2021; 48: 88-105Crossref PubMed Scopus (12) Google ScholarThe findings contextualise mental health within the pathways of transitioning education systems and establishing young adult roles. The effects of mental health on educational engagement and achievement are reiterated, as are the impacts of bullying and educational stressors on mental health. This depth of evidence requalifies the importance of considering educational settings in delivering universal and selective interventions, promoting known protective factors, and reducing stigma around mental illness.9Tomé G Almeida A Ramiro L Gaspar T Gaspar de Matos M Intervention in schools promoting mental health and wellbeing: a systematic review.Global J Community Psychology Practice. 2021; 12: 1-23Google Scholar Such initiatives have the potential to address barriers to accessing support and improve the reach of support to those at risk.Understanding how childhood antecedents and the lived experiences of young people can precipitate or heighten ongoing depressive symptoms as they transition through adolescence is central to providing holistic mental health care. This study emphasises the need for services that recognise and respond quickly to mental health distress in young people and maintain support over sustained periods of recovery and healing.10Davey CG McGorry PD Early intervention for depression in young people: a blind spot in mental health care.Lancet Psychiatry. 2019; 6: 267-272Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar In a new examination of the Avon Longitudinal Study of Parents and Children, Bryony Weavers and colleagues intricately characterise trajectories of depressive symptoms experienced from adolescence to early adulthood.1Weavers B Heron J Thapar AK et al.The antecedents and outcomes of persistent and remitting adolescent depressive symptom trajectories: a longitudinal, population-based English study.Lancet Psychiatry. 2021; (published online Oct 18.)https://doi.org/10.1016/S2215-0366(21)00281-9Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Examining childhood antecedents of early adult outcomes provides new insight into when we should intervene in adolescent depression, and with whom. The mental health burden and impairment experienced by this cohort of young people accentuate the need for comprehensive sustained services. When symptoms were assessed from age 10–25 years, only a small majority of young people (54%) were found to experience a stable-low risk of clinically significant depression. Almost half (46%) were likely to experience clinically significant depressive symptoms during adolescence or early adulthood. An empirical modelling technique, latent class growth analysis, delineated three patterns of depressive symptoms. First, adolescent-limited symptoms (14%), whereby an inclining risk of clinically significant depression from age 10–18 years had resolved by age 24–25 years. Young people whose symptoms resolved had low rates of functional impairment and high participation in education and employment by age 25 years, with history of suicidal self-harm comparable to the stable-low risk group. By contrast, 7% of young people experienced adolescent-persistent symptoms, characterised by rapidly increasing symptoms over age 10–18 years that persisted into early adulthood. These young adults had the highest rates of functional impairment (62%), non-participation in education, employment, or training (16%), and history of suicidal self-harm (27%). A further 25% of the cohort experienced adult-increasing symptoms, gradually increasing over age 10–25 years and resulting in high rates of functional impairment (42%), non-participation in education, employment, or training (9%), and history of suicidal self-harm (10%). Specialist mental health care services might support only a proportion of these young people, prioritising those with the most severe presentations.2McGorry PD Mei C Early intervention in youth mental health: progress and future directions.Evid Based Ment Health. 2018; 21: 182-184Crossref PubMed Scopus (97) Google Scholar This new population-level evidence calls for urgent examination of routes to extend this support and offer different pathways and ways to overcome the barriers to help-seeking experienced by many young people and their families.3Tylee A Haller DM Graham T Churchill R Sanci LA Youth-friendly primary-care services: how are we doing and what more needs to be done?.Lancet. 2007; 369: 1565-1573Summary Full Text Full Text PDF PubMed Scopus (461) Google Scholar The findings relied on long-term participation, and young men were under-represented. Although analytic correction accounted for cohort attrition, it is likely that many of the young people most impacted by mental health difficulties and social adversity were lost to follow-up or declined participation. Disaggregation of the burden of mental ill-health across social and cultural contexts is urgently needed to advocate equitable responses and ensure provision of culturally appropriate services.4Cook BL Hou SS Lee-Tauler SY Progovac AM Samson F Sanchez MJ A review of mental health and mental health care disparities research: 2011–2014.Med Care Res Rev. 2019; 76: 683-710Crossref PubMed Scopus (44) Google Scholar Often overlooked, a smaller group of younger children (3%) were identified for whom clinically significant depressive symptoms were already prevalent by age 10 years, and were likely to continue into adulthood.1Weavers B Heron J Thapar AK et al.The antecedents and outcomes of persistent and remitting adolescent depressive symptom trajectories: a longitudinal, population-based English study.Lancet Psychiatry. 2021; (published online Oct 18.)https://doi.org/10.1016/S2215-0366(21)00281-9Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Underscoring younger children's experiences, these findings emphasise the need for awareness and recognition of depressive symptoms within paediatric settings.5Hiscock H Mulraney M Efron D et al.Use and predictors of health services among Australian children with mental health problems: a national prospective study.Aust J Psychol. 2020; 72: 31-40Crossref Scopus (9) Google Scholar The long-reaching effects of childhood neurological difficulties, particularly ADHD and traits of autism spectrum disorder, highlight the necessity for integrated services that transition from paediatric to adult mental health care. 6Cleverley K Rowland E Bennett K Jeffs L Gore D Identifying core components and indicators of successful transitions from child to adult mental health services: a scoping review.Eur Child Adolesc Psychiatry. 2020; 29: 107-121Crossref PubMed Scopus (35) Google Scholar Looking beyond depressive symptoms, the study examined childhood antecedents and correlates of symptom trajectories to identify the young people towards whom support might be most effectively directed. Adverse childhood experiences were most common among young people with adolescent-persistent symptoms: the group with the highest number of major depressive episodes, the most significant impact on early adult outcomes, and the highest rates of suicidal self-harm. Recognition of adverse childhood experiences among young people experiencing depressive symptoms draws parallels with complex trauma exposures and responses among young people, accentuating the need for equitable access to trauma-informed and trauma-focused services.7Sweeney A Filson B Kennedy A Collinson L Gillard S A paradigm shift: relationships in trauma-informed mental health services.BJPsych Adv. 2018; 24: 319-333Crossref Scopus (135) Google Scholar The frequent co-occurrence of adverse childhood experiences with social and economic disadvantage highlights the need to address financial, language, and health literacy barriers to accessing mental health support.8Nooteboom LA Mulder EA Kuiper CHZ Colins OF Vermeiren RRJM Towards integrated youth care: a systematic review of facilitators and barriers for professionals.Adm Policy Ment Health. 2021; 48: 88-105Crossref PubMed Scopus (12) Google Scholar The findings contextualise mental health within the pathways of transitioning education systems and establishing young adult roles. The effects of mental health on educational engagement and achievement are reiterated, as are the impacts of bullying and educational stressors on mental health. This depth of evidence requalifies the importance of considering educational settings in delivering universal and selective interventions, promoting known protective factors, and reducing stigma around mental illness.9Tomé G Almeida A Ramiro L Gaspar T Gaspar de Matos M Intervention in schools promoting mental health and wellbeing: a systematic review.Global J Community Psychology Practice. 2021; 12: 1-23Google Scholar Such initiatives have the potential to address barriers to accessing support and improve the reach of support to those at risk. Understanding how childhood antecedents and the lived experiences of young people can precipitate or heighten ongoing depressive symptoms as they transition through adolescence is central to providing holistic mental health care. This study emphasises the need for services that recognise and respond quickly to mental health distress in young people and maintain support over sustained periods of recovery and healing.10Davey CG McGorry PD Early intervention for depression in young people: a blind spot in mental health care.Lancet Psychiatry. 2019; 6: 267-272Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar AF and FM report research at the Murdoch Children's Research Institute, supported by the Victorian Government's Operational Infrastructure Support Program. AF is supported by the Stronger Futures Centre of Research Excellence into Intergenerational Trauma (GNT1198270), funded by the Australian National Health and Medical Research Council. FM reports honoraria for the statistical review of the accepted manuscript by Weavers and colleagues. The antecedents and outcomes of persistent and remitting adolescent depressive symptom trajectories: a longitudinal, population-based English studyThe future course of adolescent depression can be differentiated by age at onset during adolescence, adolescent academic attainment, early and persistent adversity, and genetic loading. A detailed social and educational history could be helpful in making clinical decisions about the intensity of interventions for young people with clinically elevated depressive symptoms who seek help. Full-Text PDF