Diagnosis of anxiety disorders and depression in adolescents

Adolescence is an exciting and welcome stage of development for any young person. They undergo rapid cognitive and psycho-social development; it is marked by increased time spent with peers, as well as increased autonomy and individuation. Despite this, or perhaps because of this, it can be a turbulent period for many and there can be difficulty in differentiating signs of transient emotional dysregulation from more pervasive mental health disorders. This must be done so that early intervention can be offered if appropriate. Given their key role in health surveillance, general practitioners and paediatricians are ideally placed to contribute to early identification of more pervasive or sinister pathology, and to refer onward to specialist mental health services if required.

Prevalence and course

Clinicians must be aware that anxiety and depressive disorders not only occur in childhood and adolescence, but that they are quite common. Ignorance of this can lead to missed diagnoses and deterioration of psychosocial functioning as a result.

Anxiety disorders

Anxiety disorders are considered the most common mental health disorder in childhood, estimated to occur in 14-25%, with the most recent pooled prevalence estimate of 19%, and are more common in females.¹ The mean age of onset is 7-14 years, and as with depressive disorders, they relapse and remit over their course.² They are typically heterotypic, changing clinical type over time, and are associated with high rates of subsequent depression, increasing in risk with time. Anxiety symptoms in adolescence are very common, age-appropriate and are normal; adapting to the stressors typical of this developmental stage. They can in fact be protective, provided they are transient and do not impair the young person’s functioning. They only become pathological if they are extreme, cause significant individual distress and/or impair functioning. 

Depressive disorders

Depressive disorders, on the other hand, occur slightly less frequently; occurring in 6% of adolescents,³ and a later mean age of onset.² They also present more frequently in females, and rates of depression increase in parallel with pubertal status. Although it can present in childhood, it is quite rare; with less than 3% prevalence before the onset of puberty.³ Conversely to anxiety disorders, depression is most often homotypic in nature. They present with consistent features of low mood, with negative thoughts about themselves, their future and the world around them (referred to as Beck’s triad for depression), lasting a minimum of a two-week period. These negative thoughts can often be associated with hopelessness/futility, as well as engagement in self-harm with an active or passive wish for death. In boys and younger children, a low mood may often be displayed with behavioural difficulties and irritability. Formal diagnostic criteria are much the same in adolescents as in adults, with a few exceptions, as outlined in either DSM-5 or ICD-10. 

Assessment

As with any psychiatric assessment, a biopsychosocial approach to assessment (and treatment) must be taken.⁴ As these factors can often be nebulous, an IF-ME framework can be applied: under the headings of Individual, Family, Medical and Environmental factors, referred to as If-Me. One can apply these following a standard psychiatric assessment pro-forma. 

The need for collateral can be determined by the clinician, and is typically dependent on age, complexity of presentation, and quality of history provided by the young person. Due regard and process to issues of confidentiality need to be established at the outset, to ensure the development of a therapeutic alliance and also any safeguarding actions necessary following any disclosure of abuse. 

It is helpful to establish past psychiatric history; is this new or is it an exacerbation of a chronic mental health problem? Are they known to any services which may provide additional details, or may be more appropriately referred to? What kind of supports have they been provided and were they useful?

For youth with anxiety disorders, a typical developmental history might include a progression from early signs of behavioural inhibition, with an infant being somewhat fearful, cautious and staying close to their primary caregiver, exhibiting a strong adverse response to separation. They may report many of the normal childhood phobias, such as fear of the dark, dogs, new situations etc. for a greater or longer lasting period than others. There may be a re-emergence of separation anxiety at primary school entry, retention of childhood rituals and magical thinking, and for some, the development of obsessive-compulsive phenomena. By secondary school social anxiety (fear of scrutiny by peers, especially when the focus of attention is on them) and panic attacks (acute, often untriggered, bouts of anxiety, with difficulty breathing or fearing one might die) might become more prominent along with more general anxiety around timekeeping, accomplishments new experiences or life in general. 

While anxiety disorder might present at any age, a clinical enquiry into past development might uncover some of these predisposing features. Post-traumatic stress disorder, also a form of an anxiety disorder, may also present in youth, occurring following a ‘perceived’ threat to life or safety, and presenting with avoidance of triggers, flashbacks, nightmares and a heightened state of alertness.

For adolescents with depression, the young person may have had prior experiences of low mood, with some somatic symptoms, such as fatigue, poor sleep and appetite. For some, these moods are responsive to pleasurable activities and might suggest a dysthymic picture. For others, their low mood may be less responsible to social environment and they may show little enjoyment in previously enjoyable activities, increasing loss of interest (anhedonia) leading to increasing avoidance. Somatic symptoms are common, with either initial or middle insomnia, or excessive sleepiness, poor concentration, slow cognitive processing, memory difficulties and poor motivation. 

These symptoms can compound already low energy levels and a sense of personal incompetence. Young people may become hopeless, especially as these disorders continue to impair their functioning or if external stressors remain. These thought patterns may contribute to reduced concentration; again compounding impairments in school, home and social settings. Ultimately this can result in suicidality and thoughts of self-harm. For this reason assessment of risk is an essential part of a clinician’s duty and cannot be ignored 

Outruling a medical cause is part of the clinical assessment, and usually easily differentiated by clinical enquiry. Poorly controlled hypothyroidism or anaemia may present with a low mood, as well as reduced appetite and energy – all similar to the picture of depression. Careful consideration of these factors may be the missing piece in a diagnostic puzzle. In these cases, additional medical investigations may be warranted, and often limited to simple blood tests. The presence of an intellectual disability or ‘neuro-divergence’ (for example attention deficit hyperactivity disorder [ADHD] and autism spectrum disorder [ASD]) may require a change in communication style and tempo, and should be established early. A family assessment also assists in establishing genetic vulnerability and family dynamics. Parents may unintentionally exacerbate or reinforce anxieties, especially if a parent themselves are anxious they may over protect their child or over identify risk situations. Such factors are important to consider both as aetiological factors, but also when planning targeted treatment. 

The predominant environment for youth is school, and as such a school history is very important, with a focus on behaviour, academics and socialisation. It is essential to compare the adolescent’s developmental stage with those of others at a same stage (ie. at primary school level, children will typically be friends with their whole class and then friendships become more select in nature by adolescence. In fact, for an older adolescent to be ‘friends with everyone’ may show a lack of ‘close friends’ and could suggest socialisation difficulties). Changes in academic or social functioning may be important to assist in locating specific stressors or times of trauma that may not be evident initially. These stressors may be at home or school; they may be physical illnesses of friends/family, parental separation or school bullying. It is helpful to create a picture of home and school life, establishing a family tree and asking about specific friends, what subjects they like, what career they would like to pursue, do they have a part-time job etc. This aids in establishing a therapeutic relationship, and again can shed light on degree of adaptive functioning, resilience or problem areas that may not be so readily clear. Asking about degree and experience of social media use is increasingly important given the salience of this communication medium in young people. Adolescents are now exposed to a wider range and a more or less continuous source of stressors, given the increased influence of the internet on youths. This facilitates communication and comparison with adolescents across the world, as well as placing them in a brighter spotlight themselves through social media applications. 

Management and treatment

The core of managing anxiety and depressive episodes remains as it has been for many years – with a two-tiered approach. 

The NICE guidelines provide clear direction for clinicians. In the case of a child with mild depression, updated guidelines suggest watching and waiting for four weeks and advice is not to commence medication.⁵ There is insufficient evidence to favour one psychological therapy over another but persistent mild depression after four weeks, or sooner if depression more acute, is to offer individual non-directive supportive therapy, guided self-help or group based cognitive behavioural therapy (CBT).⁵ While this can also be trialled in moderate to severe depression initially, in the presence of significant cognitive impairment or distortions, earlier recourse to anti-depressant medication may be warranted. Youths presenting with depression and psychotic symptoms may also require anti-psychotic therapy and consideration of an inpatient setting.

All adolescents and their families should be offered psycho-education as standard, attention to sensible living by way of healthy lifestyle choice with good nutrition, sleep hygiene, exercise and avoidance of stimulants and substances. Safety plans should be openly discussed, including restricting access to medications and other ways of self-harming, in so far as is possible.  

Recommended treatment for most anxiety disorders also favour CBT, with engagement in exposure prevention therapy and establishing relaxation techniques.⁶ There is increasing evidence for mindfulness-based therapies, either alone or as adjunctive in both conditions.⁷

Medication

When medication is indicated, selective serotonin reuptake inhibitors (SSRIs) are the mainstay of medication management for youth anxiety or depressive illnesses, when indicated, having a reasonable evidence base and a generally well-tolerated side effect profile.⁸ However, given the ‘black-box warning’ on all SSRIs, due to an increased risk of suicidal thoughts or acts in addition to aggressive behaviours, fluoxetine, which had the lowest risk of this, is considered first-line medication in adolescent depression. Both sertraline and fluoxetine have been approved for the treatment of paediatric obsessive-compulsive disorder (OCD) and as first-line anxiolytics. As a general rule, prescription of an SSRIs in youth is best left to specialist mental health clinicians. Common side effects include nausea, diarrhoea, headaches, insomnia or hypersomnia, and less frequent but of relevance to youth, is sexual dysfunction. These side effects, particularly sexual dysfunction, can often be deciders in nonadherence. 

There are other families of antidepressants, some of which have roles in anxiety disorders, but as mentioned these are more appropriately left to be managed by specialist mental health services, and would not be used as first-line pharmacological treatments. With time, and further research in this age group, it is hoped that alternatives will be found for safe and effective first-line use. Given the heterogeneity of both disorders, individual youth are known to respond uniquely to pharmacological management between individuals.

Conclusion

Anxiety disorders are common disorders in youth, but the extent of associated impairment and negative trajectory, including subsequent depressive episodes, are often under-acknowledged. Depressive disorders become an increasingly impairing condition in adolescents and, when associated with self-harming behaviour, may be fatal. Strong evidence base exists for the treatment of both conditions with the advantages of early recognition and intervention recognised, and appropriate referral to specialist mental health services when indicated, for example if illness is severe, co-morbid, positive family history or family dysfunction or associated with suicidal risk. 

A multimodal approach to treatment including provision of psycho-education, psychotherapy (eg. CBT) and pharmacotherapy when appropriate provide an effective treatment for most youth. Referring the young person (and their family) to a support organisation can assist in personal agency, and a range of services are available.⁹ Ensuring the young person and family feel listened to, respected and adequately involved in the assessment and treatment options are fundamental to standard clinical approach. 

References

1. Barker MM, Beresford B, Bland M, Fraser LK. Prevalence and incidence of anxiety and depression among children, adolescents, and young adults with life-limiting conditions: a systematic review and meta-analysis. JAMA Pediatrics 2019 Sep 1; 173(9):835-4
2. Kessler RC, Amminger GP, Aguilar‐Gaxiola S, Alonso J, Lee S, Ustun TB. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry 2007 Jul; 20(4):359
3. Jane Costello E, Erkanli A, Angold A. Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatry 2006 Dec; 47(12):1263-71
4. O’Keeffe, N, Blanaid G, Cullen, W, McNicholas F. Child and Adolescent Mental Health: Diagnosis & Management: Quick Reference Guide, ICGP Quality in Practice Committee Publication Year: 2013
5. Hopkins K, Crosland P, Elliott N, Bewley S. Diagnosis and management of depression in children and young people: summary of updated NICE guidance. BMJ 2015 Mar 4; 350
6. Hill C, Waite P, Creswell C. Anxiety disorders in children and adolescents. Paediatr Child Health 2016 Dec 1; 26(12):548-53
7. Perry-Parrish C, Copeland-Linder N, Webb L, Sibinga EM. Mindfulness-based approaches for children and youth. Curr Probl Pediatr Adolesc Health Care 2016, Jun 1; 46(6):172-8
8. Cipriani A, Zhou X, Del Giovane C et al. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet 2016 Aug 27; 388(10047):881-90
9. https://www2.hse.ie/wellbeing/mental-health/supports-for-young-people.html?msclkid=987631c8a95711ec9ce2a6322e039695