How to help young people with depression

Rising numbers of young people have depression. It can affect their relationships with family and friends, disrupt their school lives and interfere with sleep. Services are struggling to meet their needs and many young people are waiting months to access the talking therapies that could help them. Sometimes, doctors might consider prescribing antidepressant medicines. Research supports the use of some antidepressants in young people, and suggests that others should be avoided

In this podcast, Helen Saul, Editor in Chief of NIHR Evidence, speaks with Bernadka Dubicka, who is Consultant Child and Adolescent Psychiatrist at the Greater Manchester Health Trust and Professor of Child Psychiatry at the Hull and York Medical School; and Felicity Jane Allman who had experience of depression as a young person and is now a medical student in Newcastle. They discuss the help available for young people with depression, and the times when antidepressants could be the right choice.

Read a full transcript of the episode here.

The views and opinions expressed in this podcast are those of the host and guests and do not necessarily reflect those of the NIHR or the Department of Health and Social Care. 

Transcript

Podcast transcript: How to help young people with depression

Intro music (00:00)

Helen Saul (00:07)
Welcome to this podcast from the National Institute for Health Research, the NIHR. This episode is about the rising numbers of young people with depression. Services are struggling to meet their needs, and many young people have to wait months – or longer - to access the talking therapies that could help them. We’ll be looking at what help is available, and exploring the difficult question of when antidepressant medicines can be the best option for a teenager with depression.

My name is Helen Saul and I’m the Editor in chief of the NIHR Evidence Website, where you can find our latest collection of research on antidepressant use in young people.

I have two guests with me today – and I’ll let you introduce yourselves. Welcome, Bernadka.

Bernadka Dubicka (00:58)

Hello Helen. My name is Bernadka Dubicka, I’m a consultant child and adolescent psychiatrist with over 30 years experience working in the NHS, treating young people with depression, and I'm also a researcher with a special interest in Young People with depression and Professor at Child Psychiatry at The Hull and York Medical School at the University of York, and Honorary Professor at of the University of Manchester, and a consultant at the Greater Manchester Health Trust.

Helen Saul (01.22)

Thank you Bernadka. And Felicity

Felicity Jane Allman (01.25) 

My name is Felicity Jane Allman, I have lived in experience of depression while I was a young person, and I am now a medical student in Newcastle.

Helen Saul (01.37)

So we know that more and more children and teenagers have poor mental health. And Felicity, you kindly agreed to share your experience of depression. So wonder if you could describe your depression and give us an idea of how old you were when it started?

Felicity Jane Allman (01.53)

I'm happy to share my experiences, putting a specific date on when I became depressed is tricky. But I do know I was about 14 when I started noticing a particularly sort of low mood, and I was in a circle of friends who were kind of having a bit of a tough time, and were using cutting as a form of self-harm to deal with emotions.

And I almost remember when we think about talking therapies, the most popular one: CBT, That's looking at your thoughts, your feelings, your behaviours, and it's interesting because I feel like the behaviour almost came first. I think, reflecting on as an adult, It probably didn't, but I was aware that I was cutting to deal with emotions before I was even aware the emotions were really there.

So 14 was when I think it probably started in earnest, and then, by the time I was sixteen, I was spending a lot of time in bed. I was having really tough time, and I took an overdose of paracetamol, which is what sort of brought me into services and and started to kind of a journey of recovery that took a really really long time, you know, depression is still something I live with now, but I do remember as a young person not really knowing where to go, who to turn to and the adults around me not really knowing what to say or do to be helpful.

Helen Saul (03.21)

Can you tell us what it was that you were experiencing?

Felicity Jane Allman (03.25)

It's really difficult now that I know so much clinically it can be quite difficult to look on myself and look back at, and not remember those experiences with a clinical eye. But I certainly have that loss of joy. So things that used to be fun and meaningful for me were no longer fun and meaningful for me, and I felt very unhappy with my appearance. I had quite bad acne, and I had this uncontrollable hair, and kids can be cruel, and so I was always, you know, the butt of of quite a few jokes. And I think I really struggled. I think some of them probably weren't meant to be nasty jokes, I think, because some of them were. I perhaps struggled to know when people were joking when people weren't. I remember this distinct feeling of not being cool enough, and so I didn't get invited to the parties, perhaps that my friends were getting invited to, and that probably became a bit of a self-fulfilling prophecy, because the more I came to resent those people, the more I would have isolated myself. I just remember spending a lot of time alone, a lot of time watching my grades dropping. I'd always been a high achiever, but my grades were dropping. I didn't really feel like I had anyone to talk to, and finding a lot of relief in just sleeping, you know, just being in bed and sleeping a lot and sleeping away quite a lot of my teenage years, and not in the usual grungy teenager sleeping all day, making quite a deliberate choice to to be under the covers, because it just didn't hurt quite so much.

Helen Saul (04.59)

It sounds extraordinarily painful, Felicity, and I’m so sorry you went through that.

But Bernadka I imagine that this kind of experience is familiar to you?

Bernadka Dubicka (05.12)

Yeah, thank you so much for sharing that Felicity, but yes, it's horribly familiar from the many, many stories I’ve heard from young people over the years. I guess there's a few things I'd like to just highlight Felicity in terms of what happened to you and in terms of what I see. And that is, Firstly, you had to reach crisis point from the sounds of it, before you got help you took an overdose before you got the help you needed, whereas you had been struggling for quite a few years from the sounds of it before that. And that just illustrates how important it is to try get that help and support early because you really described well that horrible vicious cycle, that spiral of despair people get into when they’re feeling depressed and then as you become more and more withdrawn you lose more and more contact with the people around you and it becomes even more difficult to break out of that cycle. And that is why it is so important that young people do get help early on because we know that the more entrenched those sorts of behaviours and feelings become, the more difficult it is to help people. And the tragedy is that we're seeing more and more young people turning up in accident and emergency departments over these past few years. It's just escalated since the pandemic, you know. First, you know, appearing in crisis to seek help, whereas those young people deserve better help from services and should have had that help much much earlier on. And of course, it’s not only better for the young people and their families it’s a lot better for services and and economically it’s a lot better if we can give that support much earlier on rather than wait until young people fall into crisis.

Helen Saul (06.45)

Thank you Bernadka. Could you outline for us the current guidelines for doctors who are treating young people with depression?

Bernadka Dubicka (06.52)

So the current guidelines are based on the NICE guidelines that they're originally drafted in 2005. There's been some update in terms of psychological treatment more recently. The most important things to draw out from there is: firstly, if the young person has relatively mild depression, is that the professional should wait and watch and see for a couple of weeks to see if things improve by themselves or not. And that's actually quite a sensible piece of advice for those young people who don't have severe depression, or have lots of other risk complications associated with that, because it is often difficult to tell which young people are going to improve. I've certainly seen in my experience that simply acknowledging the problem, approaching somebody, having someone listen to their problems, that it itself can be a kick start in terms of recovery, for some young people. However, if things aren’t improving over those first few weeks, NICE then suggests that young people and children with mild depression should be offered some form of psychological treatment. They suggest cognitive behaviour therapy as one form of treatment, and there are many charities like Kooth for example that do now offer online counselling, which is often informed by cognitive behaviour therapy. And there's a lot of charities like Kooth doing excellent work really in that field.

However, there's no improvement following that, then, or a person's got more severe depression, they should then get a referral to specialist services, or CAMHS as it’s otherwise known.

Bernadka Dubicka continues (08.22)

Once young people reach CAMHS, they should then get a full proper assessment. We call that a biopsychosocial assessment. In other words, looking at biological factors, you know things like physical health problems, genetics, for example, looking at the social situation and the environment the young person is living in because that is so important in terms of how that might affect mood. And also looking at psychological factors as well, for example, if a young person has got lots of anxiety or other factors like that. And once that full assessment has been done and we have looked at the strength of that young person, their family and also things that might, what we call risk factors, things that make improvement more difficult for that young person. Then we can devise a plan of action, and a treatment plan to help that young person. But NICE very much states that the first treatment approach should be psychological, and they suggest a number of therapies. However, in the more recent guidance, they have suggested that if a young person is particularly depressed, and the clinician feels it’s appropriate, and that should be a child and adolescent psychiatrist, then fluoxetine, which is a particular form of antidepressant, can be prescribed alongside talking treatment first line. So for some young people that might be considered, but for the majority they should be offered a psychological treatment after a full assessment.

Helen Saul (09.43)

Felicity, how similar was your experience of treatment to the guidelines?

Felicity Jane Allman (09:49)

I mean In some ways it's comparable, and in other ways not. Obviously, I didn't access services initially through a GP. Um When I did come to the attention of services which was through the liaison psychiatry team at the General Hospital.  I had one-to-one CBT: so cognitive behaviour therapy, the most common form of therapy at home for a course of months, which I don't think is available now. I was really lucky to have that, and I formed a really close relationship with the therapist who came to do that, and that was a CAMHS service that was offered locally, And I don't know how much I really understood CBT. I don't know how useful it was in the sense that I could really process those thoughts, feelings, and behaviours. But I do completely agree that just having somebody to talk to. I had an hour a week where somebody sat in the living room with me and said, How is the week being? And I just vented, and sometimes it was good, and sometimes it wasn't good, and I could tell her that I had a bad day, and I cut myself, and there was no, no thought of punishment. There was no telling off. There was: ‘Oh, let's explore that. What made you feel so bad?’, and it was wonderful, and I think in reflection, A lot of people could have played that role for me, and I hope that most young people would have someone to play that role for them. It would be amazing if there were a greater provision of services. But I do think so much of it is the relationship. Um, and in terms of medication. I remember being offered certainly before I was discharged from CAMHS, which is, when I was 18. I remember medication being talked about, and I remember declining that. I don't remember any of the discussions around medication. CBT seemed to be the number one option, and that's what I had.

Helen Saul (11.49)

A point made in the Collection is that mental health services are struggling to meet the demand. Antidepressant use in 12 to 17 year olds doubled between 2005 and 2017. That could indicate that young people might not be able to access talking therapies, or might be waiting a long time to see someone. So Bernadka, I wonder if you could talk us through the current situation?

Bernadka Dubicka (12.13)

Felicity's right to say that CBT might not be that freely available, but it is the most common therapy that is offered within CAMHS services. But the frightening situation is that even back in 2018, when the Care Quality Commission did a review of CAMHS services, they found that some young people were waiting for up to a year for therapy. That was before the pandemic, that was before we had the huge increase in prevalence of mental health problems particularly emotional disorders among young people since the pandemic, and we know demand has escalated massively since then. And alongside that our workforce just is really struggling to keep up. For example, around 1/12 child psychiatry posts are vacant I think, and the same goes for mental health nurses and psychologists so we are really struggling to meet the huge demand in terms of the mental health problems that people are presenting with. Really struggling to meet the guidelines set by NICE.

And I know that my service and services up and down the country that some young people are still waiting up to a year. That will depend on urgency. So CAMHS services will see young people who are um who need to be seen urgently, for example, may have suicidal thoughts of trying to harm themselves, in the way that Felicity did, much more quickly, but then of course you’ve got lots of other people, as Felicity was struggling in the early years of depression, who would be better off helped much earlier on. But it’s really hard for them to access support because CAMHS have to prioritise young people that they see who have more urgent need of help. So yes unfortunately waiting lists can be months up and down the country. At the moment, we have just started to run an NIHR trial to see if we can try and deliver a briefer psychological intervention, much more quickly using practitioners that are newly qualified, and see if we can use that workforce to try and help many more young people quickly, earlier on.

Helen Saul (14.17)

Do you think that would have helped you, Felicity? 

Felicity Jane Allman (14.22)

I think, I think if it hadn't been going on so long, I think if I haven't had what was quite like a festering wound of depression, I think yeah, you know, I think we know a lot of conditions, mental health conditions, especially even of physical health. If you can get there early you have better outcomes.  But I think a big problem is, if you think of how young I was, when it all started That would have been, I would have had to sort of come out, as it were, about how things were twice, because I would have had to tell one of my parents, and then tell a GP. Because, as a 14 year old, I wouldn't ring up my GP, and make appointments for myself. So accessing those services, I think, would still have felt like quite a hurdle. I think for adults, It's much easier to say, go to speak to your GP or self-refer I think, I wish I wish it had been nipped in the bud, I think it would have given me a few more years, a few I would have had fewer years of struggling essentially. But yeah, unfortunately I didn't, and I hope that's a service that becomes available for other young people.

Bernadka Dubicka (15.32)

Can I just add, I’d also like to say Felicity, and say that what has been happening in the past few years, the Government has introduced mental health support teams into schools. That’s still a developing programme but more and more schools should now have access to a team that has been trained in helping young people with mental health problems who are in that mild-moderate range of difficulty, as things were with you earlier on, and that's important, Firstly, to try and pick up young people earlier on at school, which is probably more accessible than, as you say, going to see a GP. And also as you mentioned earlier, the importance of having someone trusted you can talk to. And we know from our national prevalence survey that teachers were in fact the most trusted professionals that young people found they could talk to. So there’s lots of reasons to think that’s a really positive intervention. Of course, we need that process to happen a lot more quickly, for all schools to have mental health support teams really quickly, and part of that programme is that each school will have a teacher who is a mental health lead within that school as well. So the sooner that program can be rolled out the better to try, and you know, help young people at those earlier stages.

Felicity Jane Allman (16.41)

Absolutely.

Helen Saul (16:42)

So the guidelines and best practice would suggest the central role of talking therapies. But we know that young people are taking antidepressants, so I'd like to explore now which drugs they should be given. 

It's a question that's been well studied in adults, but less so in young people. The Collection noted that a review of research on depression in adults could draw on 522 trials. A similar review in young people was based on only 26 trials.

But even so, it brought together 5 recent reviews, looking at which drugs are safe and effective in children and teenagers. So, Bernadka, how would you interpret these reviews? Which drug or drugs are the most effective for young people?

Bernadka Dubicka (17.29)

I mean first, we don't have much evidence to actually look at. But of the evidence we do have, and of the reviews that you mentioned, and as mentioned within the reviews as well. There's been a very good recent Cochrane Review, which has looked at this in detail, published last year. The problem is that the majority of the trials that have been done in children and people have largely been done in the States, have largely been run by drug companies, and have largely excluded exactly the sorts of young people that we would consider antidepressants for in the NHS in this country. 

In our studies in the UK in the NHS, we found that there is no such thing as pure depression, the vast majority, more than 90%, of young people that come to see us, are complicated. They've got lots of other difficulties, usually lots of anxiety problems, potentially behaviour issues, and other problems as well. Um And we would include those in our studies, but those sorts of issues may well be excluded from studies that have been done. So we can't actually answer the question, How well do antidepressants work in the most complicated, risky group of young people that we see in CAMHS.

So that's a big caveat, before I go on to say anything else about which drugs, about the quality of the data that we do have. In terms of which medications, NICE recommends fluoxetine first line. That's still, you know, been confirmed by the recent review mentioned in your report, in our report. And also, the recent Cochrane Review also lists sertraline, which is mentioned as a second line drug within NICE, and also escitalopram. However, the NICE guidance in relation to medication is very old. Now they go back to 2005, and haven't been updated. They suggest citalopram as the second line drug. So I think it is time that NICE did look at the most recent Cochrane review and think about updating the evidence base around medication. The Cochrane review also mentioned duloxetine which isn't used yet much within CAMHS, and it would be useful for NICE to have a look at that and see what they think.

I think it's also important to say there are certain drugs that shouldn’t be used in young people. So one group is old fashioned tricyclics, and that is because they have lots of serious side effects, and aren't very effective for young people. And venlafaxine and paroxetine shouldn’t be used in young people either because they're known to have more serious side effects.

Helen Saul (19.55)

How effective can antidepressants be Bernadka?

Bernadka Dubicka (19.59)

So all we can say at the moment for this very highly selected group of young people with the least severe depression, with the least complications, they seem to produce a relatively small effect. However, another review of these medications, as well as psychological treatment, that review found that fluoxetine was just as effective as psychological treatment. So you know, it depends on the data you specifically look at but overall, I think it's fair to say that they’ve been shown to have small to potentially moderate effect for depression. But, on the other hand, if you look at the data for cognitive behaviour therapy depression, that's also been shown to have small to moderate effective effect overall. So in terms of effectiveness, there's not that much to choose between either of them.

Helen Saul (20.41)

So Bernadka, given the gaps in the data that you described, are there circumstances in which you’d prescribe antidepressants to a young person – and what sort of considerations do you have?

Bernadka Dubicka (20.54)

Everybody is different. So, NICE talks about a person-centred, but also the values-based approach. In other words, finding out what is important to that young person and their family as well. If they're involved, and also understanding. You know the practitioners to understand where they're coming from, what their values are, because some practitioners might also be against medication, or you know more pro-therapy or vice versa. So we all need to be really aware from the practising about how we convey the messages. But yeah, everybody's different. So yeah, some young people, particularly boys, for example, struggle to talk about their feelings, and and some people prefer to take an antidepressant, and if that's appropriate for them, then that you know it could be considered  But I’ve met many young people who are really reluctant to take medication, and that's important to recognize this completely you know It's a reasonable position to have, and you know, as everyone is different, It's important to have those collaborative discussions and think about the risks and the benefits both of taking antidepressants, not taking them. And here and also the same psychological treatment because that comes, you know that that comes with a commitment and need to talk, an ability to be able to talk and share feelings, and that some young people struggle with that and I guess, and finally, your experience with antidepressants, you know you won't see them as a cure but for a lot of young people, it might just be that first stepping stone to then start to give you the confidence might help you sleep might help your anxiety a little bit, and it might make help feel a bit better to give you a bit more energy, And then you're in a better position to help yourself. And for some young people they might not have been able to access talking treatments without that. But once they're on an antidepressant, they're more able to then engage in those sorts of discussions, and then make the best use of talking treatments, to continue to work on their recovery, and also to think about, you know, relapse prevention for the future as well. So it's complicated.

Helen Saul (22.52) 

One issue that is frequently raised with antidepressants is the possibility that they cause suicidal thoughts. I imagine this is absolutely terrifying for parents and must be in the forefront of doctors’ minds when prescribing. Bernadka – how do you deal with this concern?

Bernadka Dubicka (23.09)

That's been a hugely controversial issue for a long time. So in terms of the data around suicide antidepressants, and it's been shown that, roughly 1 in 50 young people receiving antidepressants might experience an increase in terms of thinking about harming themselves, or actually harming themselves. One in 50 young people taking antidepressants might have that experience, compared to those taking a dummy pill. So on that basis it's important that we do advise everybody, all carers as well to keep an close eye on the young person and to also for the child psychiatrists who prescribe the antidepressants to make sure that they keep in touch regularly and review over those first few weeks, it seems to be the greatest risk in the first few weeks but again it’s a small number of young people.

But there's two things I like to highlight about that evidence. Firstly, again, that evidence was based on all those trials that we talked about, which were based on young people who didn't actually have any suicidal thoughts to start with. They weren't done on young people who have who have suicidal thoughts, which is the young people we see that we might consider prescribing for. So again, we don't know what the side effects might be, or how important that issue is in young people who, already feeling really desperate and suicidal.

And the other point I'd like to highlight is, you know it's upsetting data. But there has been a study that looked at all the young people who have taken their own lives. From autopsy studies they look at blood levels of antidepressants in that young person’s system and found that over 90% of young people were not taking antidepressants at the point that they tragically took their own lives. So that very much points to under-prescribing at the point they were really desperate. So, it’s not that antidepressants potentially lead to people taking their own lives, it’s young people not receiving help early enough and some of them may well have benefitted from antidepressants. But it comes too late for some young people. So I think it's really important again to weigh up the risks of an untreated severe depression versus possible adverse effects of medication. Of course that will vary considerably, you know, with each young person.

Helen Saul (25.31)

Thank you Bernadka. And Felicity – can I ask how you are now?

Felicity Jane Allman (25.37)

Things are going pretty well. I'm in my final year of medical school, which has not been the easy journey. But it was important to me to do this, after my experiences. I knew that I wanted to work in mental health and suppose it's really cliche. But my thought was, what a waste to have experienced what I experienced and to have You know it felt like I lost years of my life, what a waste to experience that, and not use that to help other people. And so I trained first as a mental health nurse, and decided that. Oh, I think I do want to be a doctor. I never thought I'd get into medical school, and so I applied and got in. And now, egg on my face, I'm in my final year applying for my first jobs as a doctor, and I I hope to be a psychiatrist. I take antidepressants. I find them very helpful, but they are just one part in the list of things I need to do for my mental health. I need to get enough sleep, and do lots of exercising, socialising and rest, because it's really easy to burn out when you're doing something like medicine, and I find antidepressants probably an enabler more than anything else. I don't think they fix me. I don't think they cure me, and I, I do see go through periods where I feel really miserable, and and I would say periods where even on antidepressants I feel depressed.

But I'm very good now at sort of, I would say, almost like sending up the flares as soon as things start to feel bad. I'm pretty good at it, sort of telling my friends, telling my family, telling the medical school. All these support systems. I'm having a really rough time at the minute. I might need a bit of extra support, and I've never had a problem with that. But I don't know if I could have said that when I was younger. But I can say it now.

Helen Saul (27.28)

Thank you very much. That's very heartening to hear Felicity, after all you've been through. I'd like to finish the podcast now, by asking each of you for a take home message from our discussion. Bernadka. 

Bernadka Dubicka (27.41)

All young people have the right to have access to talking therapies as soon as they start to struggle but some young people may well benefit from antidepressants, but that should be done as a collaborative decision together with a child psychiatrist or someone experienced in prescribing to young people and just the last take home messages. Yes, of course we need to, you do need much more research in depression in young people both for antidepressants and for talking treatments, but it’s really imp that we have the research infrastructure to be able to deliver that.

Helen Saul (28.13)

Thank you. Felicity.

Felicity Jane Allman (28.15)

Everyone's experiences are so valid, and I would hate for anyone to hear that the mental health services aren’t what we would necessarily hope they are. Or the provision isn't there, and think, ‘Well, I won't ask for help’. I think it's really important to ask for help. I wish I had sooner um, and as we talked about in this podcast, if that's a teacher at school, if that's a friend, if that's a relative, please, please, please say I'm having a really rotten time, even if you don't know how to describe it yet, just as I said, send those flares up. Let people know you're struggling. It's so important.

Bernadka Dubicka (28.51)

And congratulations to you, Felicity, you know, on your journey to recovery, and I'm sure you'll make a fabulous psychiatrist, welcome to our profession.

Felicity Jane Allman (28:59)

Thank you.

Helen Saul (29.01)

Thank you very much, Felicity and Bernadka for sharing your experience, insights and knowledge of young people with depression.

We’ve heard today of the rising numbers of young people with depression and how services are struggling to provide a timely response. But there is help available for young people with emotional problems, starting usually with your GP, though a new initiative is making help available in schools. Talking therapies remain the mainstay of treatment for young people with depression, but there are times when antidepressants could be the right choice. We’ve heard of the dire need for more research into these drugs in young people. Nevertheless – the research today supports the use of some antidepressants, and suggests that others should be avoided.

So - Huge thanks again to Felicity Jane Allman and Bernadka Dubicka for talking to us today.

This is an episode of the NIHR podcast. I'm Helen Saul and thank you for listening. If you have any thoughts or comments on this or any other episodes, please contact us at: ced@nihr.ac.uk, or via our Twitter Channel @NIHR evidence. For more information about NIHR evidence and to see our Collection on antidepressants in young people, do visit our website, which is evidence.nihr.ac.uk. 

Music (30.32)