Introduction
The notion of depression has now been commonly used in society, as more people are currently raising the community’s awareness about the disease and the implications of treatment negligence. However, while acknowledging the existence and prevalence of mental disorders, most instances of depression remain undiagnosed or ignored. Thus, for example, only 40% of Canadian residents seek help with mental health management (Farid et al., 2020). The issue is especially evident in the context of adolescent mental health, as teenagers are frequently unable to recognize the symptoms themselves while isolated from their family and friends.
Adolescent depression is now one of the most widespread mental health issues. The research demonstrates that today, the rate of adolescents with depression varies between 3 and 5-6% (Ghandour et al., 2019; Alaie et al., 2021). Moreover, it is now evident that more cases of adolescent depression remain untreated (Lu, 2019). For this reason, it is critical for psychiatric nurses to dwell on the risk factors, issues related to the disease, and the potential approach to treat adolescent depression in more efficient and meaningful ways.
Risk Factors for Adolescent Depression
The age of adolescence, commonly referred to as children aged 10-19, is characterized by a variety of changes to one’s physical and mental health, as the child undergoes several stages of adjustment to the environment and separation from parental care. Generally, there are two approaches to explaining the emergence of depressive disorders in adolescence: biological and psychological (Bernaras et al., 2019). From a biological perspective, the risk factors include predisposition to low serotonin release, endocrine-related issues, and alterations in neurotransmission (Bernaras et al., 2019). Moreover, the genetic predisposition to depressive disorders plays a vital role, with a 40% chance of causing depression in children (Bernaras et al., 2019). Hence, with at least one of these risk factors in place, families and caregivers should put effort into early disorder diagnosis and management.
As far as psychological perspective is concerned, there are currently several theories that appeal to adolescent depression emergence and implications. According to Bernaras et al. (2019), the disruptions in the attachment theory may become a reason for depression, as the loss of security and sense of safety at an early age results in higher vulnerability rates later in life. Another possible risk factor is the lack of positive behavioral patterns reinforcement. Thus, children encouraged to resort to negative coping mechanisms are prone to embrace these patterns during adolescence, when they feel less supported and understood by their surroundings (Bernaras et al., 2019). Finally, the scholars assume that the emergence of depressive disorders in adolescence is related to stressful life events and socio-cultural barriers to diagnosis and timely intervention. Hence, it is critical to address some of the most common and severe challenges in treating and detecting adolescent depression.
Challenges to Diagnosing and Treating Adolescent Depression
Screening Tools
Adolescence is one of the most challenging and sensitive periods in terms of self-actualization and adjustment to the environment. For this reason, the majority of children between the ages of 10-19 tend to demonstrate mood swings, fundamental changes in behavior, and appearance changes based on rapid hormonal alterations (Clayborne et al., 2019). The combination of the stress factors manifested during adolescence serves as a significant barrier to detecting symptoms relevant to depressive episodes exclusively. Nowadays, depressive disorders have no unified screening method, so the common symptoms of depression such as continuous sadness, fatigue, unhealthy eating and sleeping patterns, tearfulness, irritability, anxiety, and suicidal thoughts can indicate depression or contribute to another physical or psychological condition (Jackson & Goossens, 2020). Although the research claims that “symptoms of internalizing disorders such as depression and anxiety increase in adolescence, especially in females,” the overall difficulty in recognizing and managing emotions known as alexithymia is common for adolescents regardless of predisposition to depressive disorders (Van der Cruijsen et al., 2019, p. 1). As a result, there are currently no methods of depression screening other than interviews and communication with the health care provider.
Care Pathway and Communication
As far as depression screening and diagnosis is concerned, adolescents are dependent on their caregivers to receive prompt and quality health care. For this reason, when demonstrating the symptoms of depressive disorders, children are unlikely to seek help on their own (MacDonald et al., 2018). Hence, when caregivers and educators fail to recognize the issue, adolescents remain at risk of developing severe depressive disorders that could follow them throughout the transition to adulthood. According to MacDonald et al. (2018), “youths’ pathways to mental healthcare were complex, involved diverse contacts, and, sometimes, undue treatment delays” (p. 1005). Naturally, the pipeline of detecting early depression signs and timely professional intervention becomes longer and more complex, with caregivers and medical professionals communicating on the child’s behalf.
Apart from the complicated pathway, the detection and treatment of adolescent depression depend on the practitioner’s ability to communicate with the patient. During adolescence, most children feel the urge to become independent and autonomous while their emotional intelligence has not fully developed yet. As a result, adolescents tend to feel shame and stigma when tackling topics such as sex, trauma, relationship with peers, and mood issues (Kim & White, 2018). Hence, the period of adolescence is characterized by the relevant need to reach out to the caregivers while maintaining mature and confidential communication with the patients. Without finding this balance, depression diagnosis and treatment become nearly impossible.
Socio-Cultural Barriers
The complex diagnosis of depression, unlike physical health conditions, depends heavily on the perception of the disease. While depression is a common word in the global culture, many people perceive depression as temporary sadness that does not require professional intervention. The issue is especially common for adolescents, as their caregivers tend to blame puberty and other body alterations on their child’s behavioral change. For example, according to one of the surveys, 30% of the study sample shared the sentiment that depression was a sign of a weak personality (Yokoya et al., 2018). With such faulty beliefs prevailing in society, caregivers and children are unlikely to recognize depression symptoms in order to be perceived as weak and marginalized from the rest of the community.
The notion of marginalization is especially relevant in the context of adolescent relationships and self-actualization. Yokoya et al. (2018) claim that adults frequently fail to seek help in treating depression because, for the first four weeks, they believe the situation could be handled without external interference. In the case of adolescents, however, the situation becomes even more complex for two reasons. First, adolescence is characterized by the urge to make autonomous decisions and isolate oneself from parental or adult supervision. Thus, it might be challenging to create the proper environment for communication. Second, the adults’ unwillingness to recognize the disease severity may affect the decision to seek assistance for the child. Personal experience demonstrates that in certain cases, children can feel guilty for acting differently, and they are afraid of approaching their caregivers because they expect punishment for deviant behavior.
While stigma and oversimplification of depression exist globally, certain social groups are more prone to undermining the seriousness of depression. Thus, in the context of ethnic and racial minorities, patients and providers can fail to recognize the genesis of chronic depressive disorder. It is generally accepted that minority groups, especially African American community, are less likely to develop depression (Bailey et al., 2019). However, it would be more accurate to say that rather than having a low predisposition, minority groups have developed higher resistance rates after decades of collective cultural trauma of discrimination, bias, and marginalization. As a result, when communicating with adolescents representing minority groups, the approach should be more culturally sensitive and different from the conventional screening patterns for Caucasian patients.
Taking risks and barriers of adolescent depression into consideration, it can be concluded that prior to treatment, practitioners, especially nurses, need to develop a tangible framework of communication with adolescents and their caregivers. A complicated diagnosis by nature, depression can be easily confused with other moods, and physiological changes, so constant supervision and public education are vital steps towards the timely and beneficial management of depression in adolescents.
Approaches to Depression Treatment
Psychotherapy
When addressing depression in adolescents, the first response for mild symptoms is psychotherapy. Currently, there are three most common psychotherapeutically approved interventions, including cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and family therapy (Beirão et al., 2020). CBT is defined as a therapy focused on “cognitive distortions associated with depressive mood and the development of behavioural activation techniques, coping strategies and problem solving” (Beirão et al., 2020, p. 4). It means that the CBT implies an analysis of the behavioral patterns and triggers that lead to a depressive episode, the recognition of one’s response to the trigger, and the development of the coping mechanisms associated with the issue.
The second approach, IPT, is aimed at analyzing the reason for relationship disruption that could contribute to the emergence of depression. According to the researchers, such an approach can be used when one of the risk factors for a depressive episode is a well-defined past trauma associated with the relationship with the closest environment (Beirão et al., 2020). This approach is considered to be highly efficient in treating adolescent depression due to the high risk of relationships being the root cause of the disorder.
Unlike the aforementioned treatment interventions, family therapy is aimed at resolving issues together with the patient’s caregivers. Such an approach can be beneficial for the families and children willing to strengthen their communication and mutual understanding of the issue. For example, if the patient’s family has a difficult time understanding their child’s trauma, and the child is willing to find a connection with the parents, family therapy presents an opportunity to exchange points of view and reach a consensus in productive communication.
Essentially, psychotherapy is rightfully considered the best approach to treating adolescent depression. Beirão et al. (2020) imply that “psychotherapy should be considered the first line of treatment in adolescents afraid of or with contraindications for medication, with identified stress factors or those with poor response to other approaches” (p. 5). Pharmacological intervention at a young age may disrupt the hormonal balance of an adolescent, whereas therapy has no evident contradictions to implementation.
Pharmacotherapy
When therapy alone is insufficient to provide quality assistance, providers prescribe medications based on the severity and nature of a depressive disorder. The most common group of antidepressants is serotonin receptor inhibitors (SRIs), as they are taken to release enough serotonin in the body and respond to external triggers (Beirão et al., 2020). This group includes fluoxetine and escitalopram (Beirão et al., 2020). Although these medications tend to alleviate the symptoms of depression within the first 14 days of therapy, pharmacotherapy frequently implies side effects such as fatigue, nausea, appetite loss, and sleep disruptions. When prescribed without plausible explanation, the patients tend to give up therapy in order to avoid unpleasant complications.
For this reason, pharmacotherapy should be ideally combined with psychotherapy or at least a proper counseling session with the general practitioner or therapist for the patient to realize the need to take antidepressants. In some cases, the therapist may prescribe a course of B- and D-group vitamins to strengthen the central nervous system and encourage natural dopamine and serotonin release. Hence, when dealing with adolescent depression, nurses should be aware that medication intake is an addition rather than the main course of treatment, as young age makes it easier to resolve issues through meaningful communication and timely response to the disorder.
Recommendations on Treatment
Public Education and Collaboration
Adolescence is a developmental stage characterized by severe stressors to the human body and mind, including hormonal development and imbalance, self-actualization, and adjustment to societal norms. The feeling of depression, mood swings, fatigue, and maladjustment may serve as precursors to various psychological and medical conditions, including Vitamin D deficiency, anemia, depression, epilepsy, and even diabetes. Since it is impossible to immediately define the root cause of depressive symptoms, parents should be encouraged to address the professional immediately after detecting the signs. The same level of cautiousness should apply to educators and community health workers at school. According to the research, a proper pattern of family-school-community collaboration can increase the success rate of timely intervention and major depressive disorder treatment (Lu, 2019). Apart from collaboration, the proactive approach to depression detection should concern parental and adolescent education on the symptoms and implications of depression. When communicating the need to address the issue, adolescents should feel safe enough to seek help from their school and parents. Otherwise, with no trusting and confidential relationship in place, children would feel ashamed and hesitant about sharing their problems with adults.
Age and Cultural Sensitivity
Many health practitioners, when working with adolescents, find it easier to involve caregivers in the communication in order to obtain an exhaustive explanation of the problem. While finding it easier at the beginning, psychiatric workers who fail to establish contact with a child find themselves at risk of disrupting the relationship. Adolescents willing to voice their thoughts autonomously want to be perceived as adults and, as studies demonstrate, provide valuable insights into their well-being. Researchers claim that adolescents are more successful at communicating their internal concerns, such as fear, sadness, or anxiety, whereas adults are mostly focused on the external manifestations of trauma, such as hysteria, irritability, anger, or laziness (Jackson & Goossens, 2020). For this reason, it is of paramount importance to secure mutual respect and trust with the patient and ensure the child that no information shared with the psychiatrist or nurse will be exposed to caregivers.
In addition to age, it is necessary to account for the cultural and social background of the child. For example, it was mentioned earlier in the paper that African Americans and other minority groups are often considered more resistant to trauma and depression. However, at the same time, they remain more exposed to discrimination and stigma related to being portrayed as weak, so it is critical to find a way to communicate the patient’s emotions in the safest way, as minority groups with untreated depression have severe mental health complications later in life (Bailey et al., 2019). The research also demonstrates that social identity and biological aspects contribute significantly to the development of adolescent depression, as children have a hard time understanding their place in the community as a representative of marginalized groups (Patil et al., 2018). In order to combat this issue, it is suggested educators and parents initiate a conversation on the matter of diversity and discrimination before the trauma becomes a full-scale mental disorder.
Conclusion
The meticulous analysis of the emergence and treatment of adolescent depression demonstrates that nowadays, there is no unified and beneficial approach to detecting and managing the disorder. Instead, nurses and other practitioners should collaborate to develop a sensitive framework of public awareness and early detection of depression symptoms. Once they are detected, communication, professional support, psychotherapy, and pharmacotherapy should be provided accordingly. In the future, the study on adolescent depression needs to include more diverse subjects and approaches to treatment.
References
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