Why Adolescent Depression Is a Global Health Priority and What We Should Do About It

Abstract

See Related Articles pp. 533, 539, and 546This month's issue of the Journal of Adolescent Health includes three articles that focus on the detection and outcome of depression in adolescence [1Naicker K. Galambos N.L. Zeng Y. et al.Social, demographic and health outcomes in the 10 years following adolescent depression.J Adolesc Health. 2013; 52: 533-538Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar, 2Kramer T. Iliffe S. Bye A. et al.Testing the feasibility of therapeutic identification of depression in young people in British general practice.J Adolesc Health. 2013; 52: 539-545Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Ganguly S. Samanta M. Roy P. et al.Patient Health Questionnaire-9 as an effective tool for screening of depression among Indian adolescents.J Adolesc Health. 2013; 52: 546-551Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]. This editorial attempts to identify some key themes arising from these studies and to contextualize the findings from a global perspective.Naicker and colleagues report on the 10-year outcomes of a cohort of adolescents in Canada and observe that depression at ages 18–19 was significantly associated with a range of adverse health outcomes, including depression recurrence [[1]Naicker K. Galambos N.L. Zeng Y. et al.Social, demographic and health outcomes in the 10 years following adolescent depression.J Adolesc Health. 2013; 52: 533-538Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar]. Curiously, though, adolescent depression did not appear to significantly affect employment status, personal income, marital status, or educational attainment. Kramer and colleagues evaluated the feasibility and effects of training primary care practitioners in screening and identification of adolescent depression, in the United Kingdom [[2]Kramer T. Iliffe S. Bye A. et al.Testing the feasibility of therapeutic identification of depression in young people in British general practice.J Adolesc Health. 2013; 52: 539-545Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. They observed that their intervention was associated with improvements in practitioner knowledge and confidence, but that screening rates were only modestly enhanced (reaching about 20% of attendees) with consequent small effects on depression identification rates. Given that the impact of training interventions typically fade with time, this modest impact even in the short-term should raise concerns about the sustainability of the effectiveness of training interventions on improving detection of adolescent depression in primary care. Ganguly and colleagues evaluate the psychometric properties of the Patient Health Questionnaire-9, a widely used screening tool for the detection of depression in adults, in an adolescent student population in India [[3]Ganguly S. Samanta M. Roy P. et al.Patient Health Questionnaire-9 as an effective tool for screening of depression among Indian adolescents.J Adolesc Health. 2013; 52: 546-551Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]. Apart from the finding that depression was common in their sample (13.3%), they report an impressive ability of the questionnaire to discriminate true cases and noncases (a receiver operating characteristic area under the curve of .94).The key messages that arise from these studies are related to, first, the public health burden of depression in adolescence, and second, the effectiveness of methods for the detection of depression in primary care and school settings. Epidemiological evidence shows that the prevalence rates of depression in adolescence tend to vary widely between settings [[4]Patel V. Flisher A. Hetrick S. McGorry P. The mental health of young people: A global public health challenge.Lancet. 2007; 365: 1302-1313Abstract Full Text Full Text PDF Scopus (1749) Google Scholar]. Although evidence is sparse from low and middle income countries, a recent study in five low- and middle-income countries reported a mean prevalence of any mental disorder in adolescence of 10.5%; the most common diagnoses were conduct disorders and emotional disorders [[5]Atilola O. Singh Balhara Y.P. Stevanovic D. et al.Self-reported mental health problems among adolescents in developing countries: Results from an international pilot sample.J Dev Behav Pediatr. 2013; 34: 129-137Crossref PubMed Scopus (31) Google Scholar]. Suicide, which is often associated with depression, is one of the leading causes of death in adolescents in all regions of the world [[6]Patton G.C. Coffey C. Sawyer S.M. et al.Global patterns of mortality in young people: A systematic analysis of population health data.Lancet. 2009; 374: 881-892Abstract Full Text Full Text PDF PubMed Scopus (777) Google Scholar]. Indeed, mental disorders are among the leading causes of the burden of disease in this age group and, among them, depression leads the pack [[7]Murray C.J. Vos T. Lozano R. et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2013; 380: 2197-2223Abstract Full Text Full Text PDF Scopus (6182) Google Scholar]. However, relative to anxiety, depression has a relatively later age of onset (a median age of onset in the mid to late 20s) [[8]Jones P.B. Adult mental health disorders and their age at onset.Br J Psychiatry Suppl. 2013; 54: s5-10Crossref PubMed Scopus (351) Google Scholar]. In part, this is because depression is very uncommon in prepubertal children. Nevertheless, as Naicker et al. observe, those who develop the syndrome for the first time in adolescence have a higher risk of developing new episodes in adulthood, and depression in adulthood in this cohort could be considered to have begun in adolescence [[1]Naicker K. Galambos N.L. Zeng Y. et al.Social, demographic and health outcomes in the 10 years following adolescent depression.J Adolesc Health. 2013; 52: 533-538Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar]. Thus, the effective management of depression is adolescence should be considered a major global health priority because it addresses a leading cause of sickness and death in this age group and potentially also affects the burden of disease in adulthood. How can this be achieved? There are at least four major challenges that will be encountered when planning a comprehensive response, and new evidence points to opportunities to address each of them.The first challenge is the low demand for health care. Demand for health care is influenced by the degree of acknowledgment of depression as a cause of suffering that is malleable to health interventions. The reality on the ground is that most adolescents, and their loved ones, do not perceive the constellation of experiences characterized by the syndrome of depression as a health condition (let alone a mental health condition). This reality is further compounded by anxieties that applying a biomedical label risks medicalization and stigmatization of normative emotional experiences and distress. There is preliminary evidence that providing adequate knowledge about mental health conditions to parents, teachers, and students can result in improved awareness about and detection of mental disorders in school children [[9]Hoven C.W. Doan T. Musa G.J. et al.Worldwide child and adolescent mental health begins with awareness: A preliminary assessment in nine countries.Int Rev Psychiatry. 2008; 20: 261-270Crossref PubMed Scopus (43) Google Scholar]. Such strategies to raise awareness, sometimes referred to as mental health literacy, are critical, and these will need to be sensitively designed to take into account the contextual factors that influence how mental health conditions are understood [[10]Jorm A.F. Mental health literacy: Empowering the community to take action for better mental health.Am Psychol. 2012; 67: 231-243Crossref PubMed Scopus (740) Google Scholar]. Furthermore, improving the availability of contextually appropriate information through media that youth frequently access—for example, social networking sites—may offer more promising approaches to increase demand than traditional methods.The second challenge is the low levels of detection of depression, both from low levels of self-recognition and recognition by providers. The use of screening measures, either by oneself or by care providers, are promising approaches. A policy- and practice-relevant question is whether screening in health care settings should be done routinely or selectively (as in the case of Kramer et al's intervention) [[2]Kramer T. Iliffe S. Bye A. et al.Testing the feasibility of therapeutic identification of depression in young people in British general practice.J Adolesc Health. 2013; 52: 539-545Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Given the findings of their study, and the generally dismal results of evaluations of training interventions aimed at improving detection of psychiatric disorders in primary care, it would appear that routine screening, followed by a diagnostic assessment by a trained primary care provider, may be a more effective strategy for case detection.Assuming there is demand and that this is followed by adequate detection, the third challenge is the lack of access to evidence based interventions. This evidence indicates that the most effective interventions for depression in adolescence are psychological treatments (both low-intensity counseling and structured treatments such as interpersonal therapy) [[11]World Health Organisation mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Mental health Gap Action Programme (mhGAP). WHO, Geneva2010Google Scholar]. However, there are very few providers adequately skilled in delivering these interventions in most parts of the world. The evidence base in support of the effectiveness of the strategy of task-shifting of psychological treatments to nonprofessional providers, and of internet-based self-guided psychological treatments, offers two promising approaches to address this barrier [12Kieling C. Baker-Henningham H. Belfer M. et al.Child and adolescent mental health worldwide: Evidence for action.Lancet. 2011; 378: 1515-1525Abstract Full Text Full Text PDF PubMed Scopus (1166) Google Scholar, 13Andrews G. Cuijpers P. Craske M.G. et al.Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis.PLoS One. 2010; 5: e13196Crossref PubMed Scopus (929) Google Scholar].Finally, we come to the prospect of prevention. Although the evidence base in support of universal strategies is thin, a recent systematic review that identified 22 experimental evaluations in low- and middle-income countries since 2000 observed encouraging results, in particular from school-based interventions, in improving emotional and behavioral well-being (but, admittedly, with less clear benefits on reducing clinical depression; Barry et al, submitted). The use of lay counselors to deliver health-promoting school interventions or community-based peer interventions offers two examples of bridging the task-shifting and prevention agendas [14Rajaraman D. Travasso S. Chatterjee A. et al.The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: A case study evaluation.BMC Health Serv Res. 2012; 12: 127Crossref PubMed Scopus (31) Google Scholar, 15Balaji M. Andrews T. Andrew G. Patel V. The acceptability, feasibility, and effectiveness of a population-based intervention to promote youth health: An exploratory study in Goa, India.J Adolesc Health. 2011; 48: 453-460Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar].In conclusion, the articles in this issue of JAH and other recent evidence emphasize the global health significance of depression in adolescence and indicate promising strategies to enhance demand, improve detection, and enable access to evidence-based interventions for prevention and treatment that, when combined, offer a genuine prospect of stemming the global tide of depression in adolescence. See Related Articles pp. 533, 539, and 546 See Related Articles pp. 533, 539, and 546 See Related Articles pp. 533, 539, and 546 This month's issue of the Journal of Adolescent Health includes three articles that focus on the detection and outcome of depression in adolescence [1Naicker K. Galambos N.L. Zeng Y. et al.Social, demographic and health outcomes in the 10 years following adolescent depression.J Adolesc Health. 2013; 52: 533-538Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar, 2Kramer T. Iliffe S. Bye A. et al.Testing the feasibility of therapeutic identification of depression in young people in British general practice.J Adolesc Health. 2013; 52: 539-545Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Ganguly S. Samanta M. Roy P. et al.Patient Health Questionnaire-9 as an effective tool for screening of depression among Indian adolescents.J Adolesc Health. 2013; 52: 546-551Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]. This editorial attempts to identify some key themes arising from these studies and to contextualize the findings from a global perspective. Naicker and colleagues report on the 10-year outcomes of a cohort of adolescents in Canada and observe that depression at ages 18–19 was significantly associated with a range of adverse health outcomes, including depression recurrence [[1]Naicker K. Galambos N.L. Zeng Y. et al.Social, demographic and health outcomes in the 10 years following adolescent depression.J Adolesc Health. 2013; 52: 533-538Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar]. Curiously, though, adolescent depression did not appear to significantly affect employment status, personal income, marital status, or educational attainment. Kramer and colleagues evaluated the feasibility and effects of training primary care practitioners in screening and identification of adolescent depression, in the United Kingdom [[2]Kramer T. Iliffe S. Bye A. et al.Testing the feasibility of therapeutic identification of depression in young people in British general practice.J Adolesc Health. 2013; 52: 539-545Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. They observed that their intervention was associated with improvements in practitioner knowledge and confidence, but that screening rates were only modestly enhanced (reaching about 20% of attendees) with consequent small effects on depression identification rates. Given that the impact of training interventions typically fade with time, this modest impact even in the short-term should raise concerns about the sustainability of the effectiveness of training interventions on improving detection of adolescent depression in primary care. Ganguly and colleagues evaluate the psychometric properties of the Patient Health Questionnaire-9, a widely used screening tool for the detection of depression in adults, in an adolescent student population in India [[3]Ganguly S. Samanta M. Roy P. et al.Patient Health Questionnaire-9 as an effective tool for screening of depression among Indian adolescents.J Adolesc Health. 2013; 52: 546-551Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]. Apart from the finding that depression was common in their sample (13.3%), they report an impressive ability of the questionnaire to discriminate true cases and noncases (a receiver operating characteristic area under the curve of .94). The key messages that arise from these studies are related to, first, the public health burden of depression in adolescence, and second, the effectiveness of methods for the detection of depression in primary care and school settings. Epidemiological evidence shows that the prevalence rates of depression in adolescence tend to vary widely between settings [[4]Patel V. Flisher A. Hetrick S. McGorry P. The mental health of young people: A global public health challenge.Lancet. 2007; 365: 1302-1313Abstract Full Text Full Text PDF Scopus (1749) Google Scholar]. Although evidence is sparse from low and middle income countries, a recent study in five low- and middle-income countries reported a mean prevalence of any mental disorder in adolescence of 10.5%; the most common diagnoses were conduct disorders and emotional disorders [[5]Atilola O. Singh Balhara Y.P. Stevanovic D. et al.Self-reported mental health problems among adolescents in developing countries: Results from an international pilot sample.J Dev Behav Pediatr. 2013; 34: 129-137Crossref PubMed Scopus (31) Google Scholar]. Suicide, which is often associated with depression, is one of the leading causes of death in adolescents in all regions of the world [[6]Patton G.C. Coffey C. Sawyer S.M. et al.Global patterns of mortality in young people: A systematic analysis of population health data.Lancet. 2009; 374: 881-892Abstract Full Text Full Text PDF PubMed Scopus (777) Google Scholar]. Indeed, mental disorders are among the leading causes of the burden of disease in this age group and, among them, depression leads the pack [[7]Murray C.J. Vos T. Lozano R. et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2013; 380: 2197-2223Abstract Full Text Full Text PDF Scopus (6182) Google Scholar]. However, relative to anxiety, depression has a relatively later age of onset (a median age of onset in the mid to late 20s) [[8]Jones P.B. Adult mental health disorders and their age at onset.Br J Psychiatry Suppl. 2013; 54: s5-10Crossref PubMed Scopus (351) Google Scholar]. In part, this is because depression is very uncommon in prepubertal children. Nevertheless, as Naicker et al. observe, those who develop the syndrome for the first time in adolescence have a higher risk of developing new episodes in adulthood, and depression in adulthood in this cohort could be considered to have begun in adolescence [[1]Naicker K. Galambos N.L. Zeng Y. et al.Social, demographic and health outcomes in the 10 years following adolescent depression.J Adolesc Health. 2013; 52: 533-538Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar]. Thus, the effective management of depression is adolescence should be considered a major global health priority because it addresses a leading cause of sickness and death in this age group and potentially also affects the burden of disease in adulthood. How can this be achieved? There are at least four major challenges that will be encountered when planning a comprehensive response, and new evidence points to opportunities to address each of them. The first challenge is the low demand for health care. Demand for health care is influenced by the degree of acknowledgment of depression as a cause of suffering that is malleable to health interventions. The reality on the ground is that most adolescents, and their loved ones, do not perceive the constellation of experiences characterized by the syndrome of depression as a health condition (let alone a mental health condition). This reality is further compounded by anxieties that applying a biomedical label risks medicalization and stigmatization of normative emotional experiences and distress. There is preliminary evidence that providing adequate knowledge about mental health conditions to parents, teachers, and students can result in improved awareness about and detection of mental disorders in school children [[9]Hoven C.W. Doan T. Musa G.J. et al.Worldwide child and adolescent mental health begins with awareness: A preliminary assessment in nine countries.Int Rev Psychiatry. 2008; 20: 261-270Crossref PubMed Scopus (43) Google Scholar]. Such strategies to raise awareness, sometimes referred to as mental health literacy, are critical, and these will need to be sensitively designed to take into account the contextual factors that influence how mental health conditions are understood [[10]Jorm A.F. Mental health literacy: Empowering the community to take action for better mental health.Am Psychol. 2012; 67: 231-243Crossref PubMed Scopus (740) Google Scholar]. Furthermore, improving the availability of contextually appropriate information through media that youth frequently access—for example, social networking sites—may offer more promising approaches to increase demand than traditional methods. The second challenge is the low levels of detection of depression, both from low levels of self-recognition and recognition by providers. The use of screening measures, either by oneself or by care providers, are promising approaches. A policy- and practice-relevant question is whether screening in health care settings should be done routinely or selectively (as in the case of Kramer et al's intervention) [[2]Kramer T. Iliffe S. Bye A. et al.Testing the feasibility of therapeutic identification of depression in young people in British general practice.J Adolesc Health. 2013; 52: 539-545Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Given the findings of their study, and the generally dismal results of evaluations of training interventions aimed at improving detection of psychiatric disorders in primary care, it would appear that routine screening, followed by a diagnostic assessment by a trained primary care provider, may be a more effective strategy for case detection. Assuming there is demand and that this is followed by adequate detection, the third challenge is the lack of access to evidence based interventions. This evidence indicates that the most effective interventions for depression in adolescence are psychological treatments (both low-intensity counseling and structured treatments such as interpersonal therapy) [[11]World Health Organisation mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: Mental health Gap Action Programme (mhGAP). WHO, Geneva2010Google Scholar]. However, there are very few providers adequately skilled in delivering these interventions in most parts of the world. The evidence base in support of the effectiveness of the strategy of task-shifting of psychological treatments to nonprofessional providers, and of internet-based self-guided psychological treatments, offers two promising approaches to address this barrier [12Kieling C. Baker-Henningham H. Belfer M. et al.Child and adolescent mental health worldwide: Evidence for action.Lancet. 2011; 378: 1515-1525Abstract Full Text Full Text PDF PubMed Scopus (1166) Google Scholar, 13Andrews G. Cuijpers P. Craske M.G. et al.Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis.PLoS One. 2010; 5: e13196Crossref PubMed Scopus (929) Google Scholar]. Finally, we come to the prospect of prevention. Although the evidence base in support of universal strategies is thin, a recent systematic review that identified 22 experimental evaluations in low- and middle-income countries since 2000 observed encouraging results, in particular from school-based interventions, in improving emotional and behavioral well-being (but, admittedly, with less clear benefits on reducing clinical depression; Barry et al, submitted). The use of lay counselors to deliver health-promoting school interventions or community-based peer interventions offers two examples of bridging the task-shifting and prevention agendas [14Rajaraman D. Travasso S. Chatterjee A. et al.The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: A case study evaluation.BMC Health Serv Res. 2012; 12: 127Crossref PubMed Scopus (31) Google Scholar, 15Balaji M. Andrews T. Andrew G. Patel V. The acceptability, feasibility, and effectiveness of a population-based intervention to promote youth health: An exploratory study in Goa, India.J Adolesc Health. 2011; 48: 453-460Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. In conclusion, the articles in this issue of JAH and other recent evidence emphasize the global health significance of depression in adolescence and indicate promising strategies to enhance demand, improve detection, and enable access to evidence-based interventions for prevention and treatment that, when combined, offer a genuine prospect of stemming the global tide of depression in adolescence. Dr. Patel is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science .