1. Depression in Adolescents and Young Adults: current best practice David Hartman Psychiatrist Child, Adolescent and Young Adult Service Institute of Mental Health, Alcohol, Tobacco and Other Drugs Services

2. Objectives Pharmacology –What to prescribe –When to prescribe –What are the risks Psychotherapy –What kind of therapy –Who should deliver it –How much do people need

3. Clinical Practice Guidelines: Depression in Adolescents and Young Adults (2010) www.beyondblue.org.au www.beyondblue.org.au Treating Adolescent Depression Study (TADS): various publications, 2003-2009 Duncan et al. (2010) The Heart and Soul of Change: Delivering What Works in Therapy

4. The guidelines in brief DiagnosisTreatmentBy whom Dysthymia or mild depression Support, self-help, lifestyle advice School or primary care Mild to moderate depression Therapy (CBT / IPT) Self help & lifestyle advice Primary care, psychology, headspace Moderate to severe depression Therapy (CBT / IPT) → add fluoxetine (Lovan/Prozac) Primary care, psychology, headspace OR specialist services Severe depressionTherapy (CBT / IPT) + fluoxetine Specialist services Treatment resistant depression Intensive therapy + fluoxetine or other meds Specialist services Bipolar depressionMood stabilizers / antipsychotics Specialist services Psychotic depressionVarious optionsSpecialist services

5. What’s missing from the guidelines? Complexity: Depression plus: –Suicidal behaviour and self harm –Drug and alcohol use –Psychological trauma and history of abuse –Parental mental illness and/or severe family stress –Developmental disorders: intellectual disability and/or autism spectrum disorders –Chronic medical conditions → Refer to specialist services

6. Pharmacotherapy Most SSRIs are superior to placebo However there is a large placebo response (especially mild to moderate depression), and superiority over placebo is quite small for some SSRIs Risk of increase in suicidal ideation and impulsive behaviour with SSRIs - particularly with adolescents

7. Pharmacotherapy Fluoxetine –Only SSRI with a clear evidence base with adolescents Sertraline, escitalopram, mirtazepine, desvenlafaxine, tricyclics –Insufficient evidence with adolescents Venlafaxine and paroxetine –High incidence of adverse effects such as suicidal thoughts and impulsivity

8. Fluoxetine When –Moderate depression, if no response to therapy (or if therapy not available) –Severe depression, in combination with therapy How much –20mg daily For how long –Six months after remission, followed by gradual discontinuation

9. Psychotherapy Cognitive Behaviour Therapy (CBT) Interpersonal Therapy (IPT) Other options

10. Cognitive Behaviour Therapy (CBT) Cognitive –Self-monitoring of thoughts, beliefs and feelings –Challenging unhelpful beliefs and encouraging positive beliefs Behavioural –Coping skills: relaxation, problem solving, distraction –Activity scheduling –Seeking out positive experiences

11. Interpersonal Therapy (IPT) Focus on current relationships –Family relationships –Peer relationships Clarification of feelings, expectations and roles Develop social skills and social competence

12. Which therapy? “CBT and IPT should be provided by professionally trained therapists … in line with evidence based practice manuals” (Beyondblue guidelines) “Because there is absolutely no evidence that one treatment for a particular disorder is any more effective than any other, it makes no sense to mandate specific treatments” (Duncan et al, The Heart & Soul of Change)

13. The Common Factors of Therapy Therapy outcome is predicted by: –Caregiver and family functioning Supporting the adolescent’s participation –Patient motivation and participation Positive expectations of therapy –Therapeutic alliance Shared therapeutic goals Agreement on therapeutic activities Patient perception of therapist’s competence, helpfulness and trustworthiness (Kelley et al, Evidence Based Treatments and Common Factors in Youth Psychotherapy. In Duncan et al, the Heart & Soul of Change)

14. Psychotherapy Other options –Acceptance and Commitment Therapy (ACT) –Narrative therapy –Dynamic psychotherapy –Solution-focused therapy –Systemic and family therapy

15. Psychotherapy When? –Moderate depression: on its own or in combination with fluoxetine –Severe depression: in combination with fluoxetine How much? –No clear research evidence regarding minimum number of sessions, frequency of sessions or optimum duration of therapy –Clinical experience suggests: Change is inherently unpredictable Weekly is probably optimal frequency Most change is achieved in the first few sessions Severe and complex depression may need long term therapy (12-18 months)

16. Take home points: the role of Primary Care Active treatment of mild and moderately severe depression –Mild: support and lifestyle advice –Moderate: medicare-funded therapy ± fluoxetine –The right therapist for the patient –Don’t underestimate the impact of GP counselling Detection and referral of complex, high risk moderate to severe depression –Queensland Health services –Private specialist services if available