Depression in adolescence

Introduction:

After considering depression as a normal state of adolescence, the majority of clinicians distinguish moderate and transient depressive feelings from the normal development of adolescence from the different forms of depression that may take place at that age. The origin of these depressions of adolescence is not univocal.

Developmental, hormonal, affective, cognitive and psychosocial changes during the pubertal period are risk factors in the prevalence of depression in adolescents. If neurobiological vulnerabilities are indisputable, a common cause is family situations (bereavement, depressed parents, family conflicts, divorce) or existential situations (sentimental disappointment, school failure, physical illness). Another factor is undoubtedly the cultural and social pressure which, at this age where hope and idealization are natural movements, leads some young people to live the world as disappointing, too restrictive or worrying about the future.

Epidemiological data:

The mood swings of boys and girls ages 13 to 20 years have been neglected and often attributed to the normal process of adolescence. The prevalence of depression varies between 2 and 8% of the general population (according to the studies) for the Major Depressive Episode (DSD) according to the criteria of the Diagnostic and Statistical Manual (DSM) -IV in adolescence.

This prevalence increases with age at adolescence and there is overall a female predominance (2 girls per 1 boy). The depression of the adolescent is also increasing for 30 years (but also better recognized). Alongside this “severe” depression, there is a depressive mood that ranges from 28% to 44% of the general population and achieves a true depressive gradient ranging from “normal” to severe depression.

The prevalence of depression in adolescence is significantly higher than that of childhood (2 to 5 times greater).

Many depressive episodes of adolescence were not preceded in childhood by a first depressive bout. But all of the studies confirm that the occurrence of depressive disorder in childhood constitutes a significant risk factor for another depressive episode when the child grows up and becomes an adolescent. Kovacs’ work made it possible to differentiate the risk of relapse or chronicization according to the type of initial depressive disorder. They show a significant risk of depressive relapse in adolescence in children with the first major depressive episode and / or dysthymia.

On the other hand, a reactional depressive disorder secondary to a temporary problem does not represent a priori any risk of pejorative evolution.

Clinic:

More or less apparent, an EDM must be systematically sought after adolescence. It is based on the characteristic signs described in the DSM and in particular depressive mood and / or irritability, marked decrease in interest and pleasure, two symptoms present practically all day and every day for 2 weeks. Although depressive symptoms in adolescence are very similar to those of adults, there are nevertheless some peculiarities:

• Despite the psychomotor slowdown, the adolescent almost never presents a “mask of depression”. His face does not have a depressive appearance;

• transient motor inhibition are frequent in adolescence (gestures return to their vivacity and fluidity during an activity) but they can not in any case be used to refute depressive syndrome;

• DSM states that irritability often replaces depressed mood;

• The adolescent rarely says that he is sad and depressed, but he says “he’s tired,” “he’s empty-headed,” “he’s bored.”The clinical relationship is very important in adolescence.

It is by showing a “concern for care” and by asking the right questions in a context of a positive therapeutic alliance that the consultant can allow the adolescent to recognize and then to reveal his symptoms of suffering only very often it seeks to deny or silence.

Many symptoms may mask depressive syndrome in adolescence and may be considered as depressive equivalents: aggressiveness, acting out (fugues, theft), body-centered conduct (anorexia nervosa, obesity, somatic complaints), behavior sexual anarchy, drug addiction, instability, school phobia, repetitive accidents. Such symptoms must therefore systematically lead to depressive syndrome.

Girls and boys do not express depression in the same way. The former express this discomfort by their preoccupations with the image of their body, their weight, more or less diffuse pains that do not worry at first but whose intensity, persistence and above all the taking into account of the ” implicit call-in must be particularly evaluated. The latter show more their depression in a behavioral, aggressive form, thus relieving their tension and the suffering they feel in relation to the negative image they have of themselves, hidden by an apparent insolence or violent reaction which are only manifest expressions.

Comorbidity:

The comorbidity of depression with various psychiatric disorders reaches rates of 40% to 70% in the EDM and 40 to 90% in depressive disorders.

Anxiety disorders (30 to 80%):

It is the association most often encountered. In the case of an association between an anxiety disorder and depression in adolescence, depression is more severe and more difficult to treat.

Conduct disorders (10 to 80%):

These are violations of social norms and norms: truant school, fugues, thefts, lies, violence.

Consumption of products (20 to 30%):

In depressed adolescents, tobacco consumption would be doubled, by three for alcohol, four for cannabis, and ten for other drugs.

Suicide attempts (TS):

There is a clear correlation between depression and attempted suicide. Between 50% and 70% of the subjects who performed SC showed an obvious depressive problem. The presence of a depressive disorder multiplies the risk of TS by a factor of 11 to 27 compared to the general population. About 50% of depressed adolescents present suicidal thoughts or behaviors. There is a correlation between the severity of TS and the depth of the depression.

Several studies report an increase in the rate of TS when depression is associated with previously mentioned comorbid disorders (anxiety disorder, behavioral disorder, consumption of products).

Psychopathological Approach: Different Types of Depression in Adolescence

The presentation of the different types of depression here rests on a psychodynamic understanding of the psychic functioning of the depressed adolescent. Depressive problems (which arise because of various factors) affect the overall organization of the adolescent’s personality, by reinforcing certain traits or disorganizing a difficulty acquired or transitory stability (as is most often the case during adolescence).

Identical to any age of life, the depressive problem is marked by the loss of object, narcissistic withdrawal and oral fixation, ambivalence and aggressiveness. Adolescence as a developmental stage of any individual is often described in terms that would apply equally well to the description of a depression or a fight against depression.

The more or less intense presence of these aspects during the normal process of adolescent development is an argument in favor of the hypothesis that there is no adolescence without depressivity.

The affective manifestations of adolescence (depressed mood, boredom, moroseness) encountered in the usual way seem to be seen as a warning signal or defensive attitudes towards depression and not as depressive states properly so called.

Depressive problems in adolescence:

Adolescence is a stage of development marked by multiple transformations, both physical and psychological: hormonal upheaval with development until maturation of primary and secondary sexual characteristics, revivification of Oedipal and archaic infantile conflicts, rearrangements of narcissistic and objective equilibria, re-emergence libidinal impulses with possible accession to an agitated sexuality and aggressiveness. All this requires the resumption of the separation-individuation process begun in childhood. The identifications are perpetually questioned and reworked.

During this physiological period of reorganization of the personality, a depressive affect is frequent without this being a genuine depressive illness. Every adolescent is confronted during his development with a depressive overflow due to the double threat of narcissistic wound and object loss associated with the indispensable work of empowerment-individuation (rearrangements of relations with the first objects of parental love, research of new love objects outside the family). Clinical depression only occurs when the psychic apparatus fails to develop this threat, and still demonstrates a defensive ability to “build” and maintain this type of response (and avoid psychotic disorganization).This failure and its consequences are most often related to a pre-existing vulnerability (either infantile links, self-esteem or both that are interdependent) related to the subject’s history.

Losses and separations:

The depressive affect in adolescence is related to a problem of mourning due to feelings of loss:

• loss of the infant body and primary maternal bond due to pubertal transformations;

• loss of idealized parental images;

• Loss of self-esteem, as a result of the confrontation between the personal and parenting aspirations of adolescence and reality.

But depression is not so much related to these experiences of inescapable losses as to a necessity of adaptation of the psyche of the child to its development or the evolution of its status.

Reversal of the narcissico-objectal balance:

It is in adolescence that the subject must be positioned in relation to the problems of separation / individuation and dependence / autonomy with respect to the object, that is to say essentially, object as object of need, desire, enjoyment.

The question of depression is related both to the internal object and the constitution of the subject, generating here a narcissistic axis of depression, that with the external object inducing then a different depressive mode: depression of object. These two poles are obviously linked and sometimes interdependent and interacting. Psychoanalytic conceptions do not, however, oppose a neuro-biophysiological or genetic perspective of depression. Indeed, it is also with the latter that the individual has to deal with in order to constitute himself. But the human subject is constituted (as human and subject) only in relation to the other. It is thus constituted around and through its object relations.

With the process of separation-individuation, adolescence reacts to the first experiences of separation and loss.

At the moment of crossing the border of the world of childhood and the family world, the adolescent will be confronted with the testing of his internal world and the quality of the first relationships and internalizations. The teenager must separate from his parents while appropriating part of what comes from them. For any adolescent, the necessary evolution of the links can be dangerous, especially since the early links will have been problematic, due to a defect or an excess of presence. The necessary distance, experiencing the acquired with the parents, will reactivate the anxieties of separation and highlight the dysfunctions of the early attachment.

With the advent of puberty, objects of libidinal investment can no longer be identical to objects of narcissistic investment, no matter at the beginning of the genital push, the intense desire of the young pubescent to make them coincide.

Henceforth, there is an irreducible gap between “the objects of primary love” and “the objects of genital love”. This gap is at the origin of the narcissico-objectal conflict which appears as a specificity of adolescence. Indeed, at this age, everything happens as if investments of objects could only be made at the expense of narcissistic investments and vice versa.

The attraction to the object is experienced by the adolescent as a threat to his narcissistic integrity. There is, in fact, an increased and physically feasible instinctual drive: the awakening of incestuous and paristicid desires and the Oedipal conflict, without any new object choices being able to ensure their satisfaction and to constitute sufficient displacements with respect to the parental imagos.

Depression in adolescence may be due to the impossible renunciation of a “filling object” (excess of link to internal objects), an attempt to triumph over a “failing object” (lack of narcissistic weaving), or destroy an “exciting object” (narcissistic fragility in connection with a relation of symbiotic objects). Adolescence acts as a revealer and an interrogator of the quality of identifications and more generally of internalizations. Early narcissistic deficiencies in turn reinforce the object need and the importance of objects, giving them an antinarcissistic power, increasing their exciting role and their sexualisation.

In addition to changing relationships with parents, there are also the ups and downs of peer relationships.Adolescence is the period of first love. The way in which these will be perceived and managed depends very much on what the adolescent represents for himself in relationships, knowing that this representation is part of the continuity of childhood relationships.

Subdepressive Syndrome: Below Depression in Adolescence

Depressed mood, boredom, gloom:

The depressed mood is “a devaluing gaze focused on oneself and which comes to color displeasure the representations, the activities and the affects”. It is common in adolescents.

It is, however, not constant, the frequent “mood swings” being much more characteristic at this age than a stable and continuous mood whatever. This depressed mood nevertheless represents a threat and can be a warning sign of a loss of self-esteem. But most often in the adolescent it is intermittent and rapidly dissipated by the emergence of an inverse movement linked to an external ideal of the self on an action, an ideology, a group or an individual.

According to Georgiades, among the nine DSM criteria, only depressive mood is predictive of an EDM in the following year in adolescence, but this risk is increased by association with other symptoms ( anemia, eating disorders, sleep disorders, asthenia, feelings of devaluation or excessive guilt, difficulty thinking).

Boredom is characterized by a lack of interest, a sense that time does not elapse, that it is useless to make an effort to get something, that everything is always the same.

Nevertheless at the base of boredom, there is always a kind of expectation. Boredom is a frequent sensation in adolescence.

Boredom is almost always accompanied by inhibition: inhibition of affects, motor inhibition, intellectual inhibition. It seems to shield internal conflicts, anguishing fantasies. It often seems to be the representative of a more or less latent or deep depressive state. However, the experience of boredom remains essential in adolescence with the concomitant experience of passing time.

Moroseness is a particular aspect of the “depression” of any adolescent initially described by Pierre Mâle. For the latter, “we have not found other words to define this particular state for certain adolescents, which is not depression with its character of anguish, formal inhibition, expressed guilt, etc. is not psychosis … It is a state that manifests rather a refusal to invest the world of objects, beings … Nothing serves no purpose, the world is empty. These formulas may appear depressive, but they are not integrated into the thymic framework. They are compatible with apparently conserved energy. Thus Pierre Male explains very well the difference between depression and this vague, diffuse sensation, at the limit of the normal and the pathological.

Like boredom, moroseness is an unstable, changeable state that keeps the adolescent on a kind of ridgeline, in a state of disinvestment, but at the same time ready to invest something, in a state of expectation , challenging all hope.

Whether it is boredom, gloom or depressed mood, we must insist on the intermittence of these states, on their fluctuations and rapid changes. The adolescent retains positive investments (school, cultural, sporting, affective).These states do not belong to the field of pathology but can lead to it.

“Depressive Threat Syndrome”

It is an organization that is neither the adolescent crisis described by Male or Kestemberg, which in fact covers the normal adolescence process with its usual avatars linked in particular to the grieving work characteristic of this process, the invasion of the whole personality by the depressed organization, leaving no room for any other mode of functioning. This organization known as the “depressive threat” always combines two anguishing representations, that of a separation from the parental objects and that of a bond with a new sexual object. But because of factors related to situational and personal aspects resonating with each other, these two representations become of such a conflictual nature that the danger represented for the ego by one and the other, and even more by their conflictuality, leads the subject to feel a sense of overflowing, and thus risk of impotence and renunciation in which the object investment and the sexual libido are threatened to be supplanted by the narcissistic investment and the aggressiveness returned against the subject. To this psychopathological organization there corresponds a clinical syndrome manifested by the more or less brutal appearance of an apprehension or even an intense terror of feeling invaded by sadness, cockroach and suicidal ideas. The predominant disturbance of this disorder is acute or sub-acute anxiety, the essential characteristic of which is the fear not of a specific object, situation or activity, but the fear of feeling overwhelmed by a depressive affect some of which elements may arise at times, but never persist for more than a few minutes to a few hours. The symptom most often experienced is a feeling of physical and psychic tension, accompanied in a varied way by neurovegetative disorders. This depressive threat occurs readily in adolescents who, during their latency period or their prepuberty, sometimes even from childhood, have exhibited neurotic traits whose intensity and symptomatic manifestations go beyond the framework of normal childhood neurotic development.

Inferiority Depression:

This type of depression is a characteristic form during adolescence. The decline in self-esteem and the feeling of inferiority that follow are common to all depression regardless of age. But the vagaries of self-esteem in adolescence make people of this age particularly vulnerable to this type of depression. It is characterized by a set of feelings called “inferiority” related to a particular area, school or physical, for example, or to the whole personality. To this feeling is associated most often the feeling of not being loved or appreciated and an objectual disinvestment which results in a disinterest in the outside world or a search in the external world oriented towards the proof of its value. We are here in an essentially narcissistic problematic, the only conflict residing in the impossibility for these subjects to realize the ideal requirements that they give themselves. These ideal requirements often take on a megalomaniacal form, which itself seems to fill a threat of identity loss. From the confrontation with this model of perfection constituted by this ideal of the ego to which the superego compares, the adolescent’s ego will develop feelings of inferiority characteristic of this depression.

Depression of abandonment:

It is evoked from the outset in front of a teenager whose symptomatic expression is dominated by the passage to the act self-aggressive heteroou. While not all adolescents responding primarily to acting out do not have this type of depression, special attention can be given to any adolescent who becomes active when this behavior is prevented for some reason. Indeed at this moment, in a certain number appears a depression in which the feelings of abandonment, of emptiness and memories of traumatic separation are evoked. It is these same adolescents who for JF

Masterson presented a borderline syndrome based on the intensification of defenses against the second phase of separation-individuation, alone or in combination with effective separation in early adolescence or even in pre-puberty.We find here a psychopathological explanation of certain acts considered as depressive equivalents (taking drugs or excessive food, disorderly homo- or heterosexual relations, gripping relations) which serve to fill this void evoked.

Psychotic depression and melancholic depression:

As for bipolar disorder in contemporary classifications, it should be noted that in adolescents this disorder is much more frequently encountered than previously imagined and that it shares significant similarities with the equivalent disorder in adults.

Whether clinically unipolar or bipolar, melancholic depression is encountered in adolescence. Although this depression may be slightly different from that of the adult in terms of symptoms (relative frequency of delirious or confusing hallucinatory manifestations in adolescents), it is in all respects comparable from a psychopathological point of view the possible transition from one type of depression to another, and their more often encountered involvement in adolescence than in adults.

Location:

In the case of depressed adolescents, the family environment is often considered part of the etiopathogenic context.The problems are not in the same way depending on the type of depression presented.

In the case of the anxio-depressive reaction, the family environment may play a triggering role when this reaction is related to a marital disagreement, divorce, alcoholism, death of a parent, or control the excessive demands of the parents hindering the wish of separation from the adolescent who can only express this wish in the form of this brutal reaction. But the family environment can also play a protective role when this reaction is linked to the failure of a romantic relationship, a sentimental break, a scholastic or professional difficulty or a conflictual relationship with another adolescent or peer group .

In the case of depression of inferiority, the adolescent’s megalomaniac ideal is often maintained by one of the parents who has long since projected his own megalomaniac ideal on his child. Through their children these parents defend themselves from their own depression.

In the case of abandonment depression, it is easy to understand that parents can be directly affected, especially the mother. Recall that this depression of abandonment is understood psychogenetically as the revival in adolescence of feelings of abandonment occurred between 1 year and half and 3 years. At the moment when the child seeks to be individual, he is confronted with the mother’s difficulty in enduring this separation; this difficulty causes her to discourage any act of individuation by withdrawing all support for her child.

Thus the first feelings of abandonment are born. For JF Masterson, this mother suffers from a borderline syndrome. At the time of the second phase of separation-individuation constituted by adolescence, the separation of the environment, in the form of a concrete physical or emotional separation, reactivates the feeling of intrapsychic abandonment which is returned to the unconscious, but which has blocked for all the childhood the evolutionary approach towards a deep intrapsychic autonomy. This situation is found in “abandoned histories” but also in “histories too symbiotic”. Abandoned stories are those in the adolescent’s past of many placements and a series of successive failed separations.

Too symbiotic stories are those in which a teenager very attached to his mother is very often found, attachment strengthened or not by concrete situations: son or single daughter, single mother raising her child …

In the case of melancholic depression, it is relatively common to find in one or other of the parents a pathology identical to the point that this finding is an important element of the diagnosis. Here, a genetic hypothesis is often mentioned. Nobody today denies the many arguments in favor of genetic transmission in bipolar disorder. However, the only genetic point of view seems to be too restrictive: when a teenager has a melancholic depression and either parent has the same type of disorder, identifying and counteridentific movements must be taken into account.

Socio-cultural approach:

The depression of the adolescent has been increasing for 30 years. Nevertheless, it can not be said that there is a societal evolution in which adolescents are worse than in previous generations. There is no point of comparison since in earlier times, one was not so attentive to this disorder.

Before, the teenagers evolved in a more rigid but had an effect of countenance. Currently, teenagers have greater freedom, are less framed. They are more free but this greater freedom is not necessarily easy to assume and could contribute to the development of depressive affects.

From a transcultural point of view, the existence of a universal depressive nucleus is postulated, which can be expressed in a differentiated way, leading to the comparison of symptomatic variations from one culture to another.The comparison of 2200 American teenagers, belonging to four ethnic groups, Anglo-, Afro-, Mexican- and Latin American, shows, for example, the prevalence of somatic complaints in Latin American and Mexican-American groups.

The elucidation of the meaning of the disease for the society in which the subject is inscribed is indispensable and makes it possible to define appropriate therapeutic means. In practice, apart from an ethnopsychiatry consultation, a few simple rules, summarized by Moro and Baubet, help to guide a first practical approach: to be sensitized to the cultural dimension (otherwise the patient will not speak of it), to allow to the family to explain the meaning of what happens to her, if possible to use the mother tongue, not to judge even if we do not understand. You have to respect the cultural rules and be wary of too much intrusion.

Biological Vulnerability:

The study of the role of genetic factors in the etiopathogenesis of mood disorders reveals an undeniable genetic susceptibility, especially for bipolar disorders.

Nevertheless, no model of transmission is currently demonstrated and it is probably complex.

Studies show neurobiological abnormalities in adolescents with mood disorders: morphological abnormalities, in particular volume abnormalities of the amygdalohippocampic complex but also abnormalities in functional imaging. But the scarcity of studies, their small number of subjects and the often contradictory results do not allow to draw any significant conclusions.

It is unclear whether these abnormalities may be due to depression or whether they should be considered as a consequence of a depressive episode and its possible disorders.

Some authors have mentioned a hormonal factor in explaining gender differentiation in favor of girls: estrogen release in girls at puberty may play a facilitating role, whereas the release of androgens in the boy may play a role either protective against depression, or concealment by promoting behaviors that mask depression.

Evolution and prognosis:

Average duration of EDM in adolescence:

In adolescents, EDM lasts on average 7-9 months, with 80% of adolescents recovering after 1 year, but 10% continue to be depressed. The persistence of EDM is associated with the severity and age of depression at first identification, comorbid disorders, negative life events, and neuroendocrine dysregulations.

Schematically the depressive syndrome of the depressed adolescent evolves differently according to the psychopathological form.

In the case of anxio-depressive reactions, the evolution is often rapid towards a disappearance of the depressive state and a more frank reappearance of the background traits of the personality.

For depression of inferiority and perhaps even more for depression of abandonment, the evolution will depend essentially on the treatment envisaged, its application and its unfolding.

The evolution towards a pathology of character remains a lesser threat to the adaptation of the subject than a psychotic collapse always possible in adolescents presenting this type of depression.

Frequency of recurrences:

The fate of the depressed adolescent is of concern, with some having a recidivism rate above 60%. The most recent work suggests that there is a high risk of depressive relapse in the adult life of adolescents who had a first EDM at that time, irrespective of the psychopathological organization involved. On the other hand, a depressive episode in adolescence increases the risk of other psychiatric disorders and social dysfunction in adulthood.

Evolution towards bipolar disorder:

Approximately 20% of adolescents who have experienced a depressive episode will develop a bipolar thymic disorder.

Only regular follow-up for 18-24 months can provide certainty for a diagnosis of bipolar disorder in adolescence after an initial depressive episode.

Some presumptive elements could be described as the rapid onset of symptoms, family history, and mood reversal induced by antidepressants. We must emphasize the frequency of psychotic signs (delusions, hallucinations, disorders of thought) and a more “mixed” mood in adolescent bipolar disorder than in adults. Moreover, evolution is most often marked by rapid cycles (ie more than four episodes per year).

Treatment:

According to the recommendations of the French Agency for the Safety of Health Products (AFSSAPS), the first-line treatment of depression in adolescents is psychotherapy. The prescription of antidepressant medication may be considered in the second instance in the event of inadequate efficacy of psychotherapeutic management or in the event of a worsening of the symptomatology. It can be proposed more rapidly in depressive episodes characterized by severe intensity. In the present state, we propose an antidepressant of the class of serotonin reuptake inhibitors (SRI).

Adolescent response to placebo (approximately 30%) is also important.

Evaluation Consultations:

In practice, the management of a depressed adolescent begins with a careful assessment of the situation during evaluation consultations: assessment of individual semiology and psychopathology, assessment of family and social interactions. Suicidal risk is assessed and comorbid disorders are sought. These interviews can sometimes have a therapeutic effect, especially in the case of subdepressive syndrome: unveiling, enunciation, clarifications of difficulties and symptoms as well as interviews can have a certain therapeutic effect.

Often these encounters are the first opportunity for the adolescent to talk about his inner world, his affects, emotions, thoughts, dreams or dreams, without being judged on moral or ethical grounds, or be taken immediately in a parent-child parent authority relationship.

It is this new relationship that sometimes allows for rapid improvement. These interviews can also have an effect in the field of family interactions. The remembrance of family history makes it possible to introduce the dimension of time, relativizing the current intensity of difficulties, playing a cathartic role by displacing the lines of conflict, opening new spaces of curiosity and interest.

In the absence of rapid therapeutic effects, these interviews aim at obtaining a primary therapeutic alliance whatever the treatment envisaged (psychotherapy as chemotherapy).

In most cases, it is useful to propose multifocal support. These allow the adolescent to be relieved of excessively large transference movements by deploying his investments on several distinct individuals.

An adapted and individualized care is put in place with the adolescent and his family. These interviews make it possible to evaluate the adolescent’s ability to take an interest in his or her inner world and thus to choose an appropriate relational therapy.

Relational therapy:

Whether it is interviews on demand, short or long psychotherapy, analytical psychodrama, psychoanalysis, or cognitive and behavioral therapy, this type of approach is in any case desirable. L. Vaneck insists on “the restructuring value of encounters with their twofold sense of identification and narcissistic reinforcement by the consideration of themselves by the therapist”. Psychotherapy aims to unravel the narcissistic-objective impasse in which the adolescent finds himself, motivating desires towards the other in which the adolescent can find himself without losing himself. Long-term therapies are probably more feasible in the case of depressions of inferiority and in anxio-depressive reactions when the neurotic aspect of the personality appears clearly behind this reaction.

However, the depression of abandonment and the borderline syndrome that is frequently associated with it are of increasing interest to psychoanalysts; let us remind here of the difficulty to bear and to understand the passages to the act, the temporary breaks and the transgressions to the rule that enlace this type of psychotherapy.

Corcos demonstrates the importance of a bifocal treatment, which involves two therapists, each in a different time and place. Listening to one (most often the psychiatrist consultant) takes more particularly into account the “external reality” (medical, academic, social) of the patient on which he can authorize himself to intervene actively. Listening to the other speaker (the psychotherapist) lends itself to that of the “internal reality” of the patient.

Psychotherapies of psychoanalytic inspiration:

More often than not, psychotherapies of psychoanalytic inspiration are face to face, the main quality of which lies in a tailor-made, flexible approach, and in the possible confrontation of an adolescent with an adult. This method limits the risks of regression and is the method of choice in adolescence. Taking into account individual, but also family and institutional resistances is essential. The therapist must leave out silence and absolute neutrality, and accept a more active role.

However, we can distinguish brief, dynamic psychotherapies whose principles remain very close to psychotherapies of psychoanalytic inspiration but whose framework is upset by the prior determination of a short duration.

Basquin recalls several countertransferential traps described in the psychoanalytic psychotherapies of depressed adolescents: positioning as a parental rival, contempt for data of the subject’s everyday reality, lack of real availability and flexibility, absence of tolerance to acted conduits.

Psychoanalytic individual psychodrama:

Major depressive episodes are not in their acute phase an indication of psychodrama, insofar as the pathology reaches the full potential of the adolescent’s ability to play.

On the other hand, moderate depressive disorders, or major depressive disorders, seem a good indication of psychoanalytic psychodrama. In the case where the constraint of a privileged dual relationship with an adolescent causes fear of an uncontrollable psychological regression, psychodrama is a good alternative.

Nevertheless, there are not yet systematic studies carried out in depressed adolescents, authenticating the efficacy of psychoanalytic psychotherapies, but many clinical vignettes report clinical improvement.

Mediation Therapies:

These may include body-mediated therapies (relaxation, sports activities), imaginary or creative mediation (expression, writing) or other therapies. Mediated therapies are an alternative to psychoanalytic psychotherapies in adolescents for whom verbal dual contact with an adult seems too distressing, or in those who have an investment of thought in avoidance or on the contrary in over-investment . Mediated therapies aim to revive the activity of thinking most often in younger adolescents and ultimately to the possibility of analytical psychotherapy.

Cognitive therapies:

In recent years, studies, mostly in the United States, have shown the effectiveness of cognitive and behavioral therapy (CBT) in adolescent depression in group therapy or individual therapy. At present, there is no consensus among the various studies as to the value of an association between CBT and IRS.

Interpersonal therapy:

Also, an American study shows that interpersonal therapy would have better outcomes than supportive psychotherapy.

Group Therapies:

Group therapies are very interesting in adolescence.

The group helps the adolescent detach from the family environment during the individuation process and allows peer socialization. All psychotherapeutic approaches can lead to group applications. Group preparation is essential to avoid premature exits.

Chapelier recalls that the composition of a therapeutic group of adolescents must take into account the age of the different subjects, or even better their pubertal development.

Place of the family:

Since depression in adolescence is very often related to family factors, it is natural to imagine the importance of a family intervention in this pathology. It is therefore essential to involve the family, especially the parents of a depressed adolescent, in the management of their disorders. The meetings with the parents will most often have to be repeated.

Their purpose is to collect anamnestic information but above all to identify elements on the quality of the relational transactions between the adolescent and his parents. Flexibility and coherence of relationships are evaluated or, on the contrary, the presence of mechanisms impeding the development of adolescent autonomy. An attempt is made to identify the parents’ ability to mobilize and help their adolescent sufferers. It is possible to show a correspondence between the depressive moment suffered by the adolescent and a parental crisis. Sometimes, the teen’s depression echoes memories or parental affects. The meetings should be aimed at establishing a climate of therapeutic acceptance and allowing everyone to mobilize in the direction of a concerted organization of care.

Family care improves the prognosis for the adolescent and the satisfaction of families. Helping the parent on a differentiated time (parenting, parenting) is very important and should be almost systematic but not always feasible.Recall with Winnicott the importance of the real mother and the real father.

Parents must survive. The therapist should not be a better parent compared to real parents, often a significant risk.

Medication treatments:

Following the reassessment in children and adolescents of the risk of antidepressant drugs by the European Medicines Agency (EMEA), IRS and related anti-depressants do not have marketing authorization (MA) in the treatment of depression in patients under 18 years of age. It is stated in the text that their use is “discouraged” in this age group. Nevertheless, it is sometimes necessary to resort to it in the clinic, but with certain precautions.

The role of antidepressants is not negligible when the psychomotor slowdown and the basic depressive affect completely or partially hinder the relational approach.

Any prescription requires several preliminary interviews and must be accompanied by close monitoring (regular interviews). The prescription must be carefully discussed with the adolescent and his / her parents and obtaining a therapeutic alliance from them is paramount. The patient and his family should be informed of the risks of the treatment and in particular of the risk of developing hostile or suicidal behavior at the beginning of treatment in order to help the practitioner to detect it. They are also informed about what the adolescent can expect from the treatment and how long it will last. The question of the need for short-term hospitalization is systematically discussed. It is recommended to start at a low dose and gradually increase to the minimum effective dosage. Discontinuation of treatment should also occur gradually.

The prescription of antidepressants is not adapted to emergencies, which require hospitalization. In all cases, the prescription of antidepressants must be accompanied by adequate psychotherapeutic management.

Studies report the efficacy of fluoxetine, sertraline, citalopram, and paroxetine for adolescent depression, although not all studies of this type are unanimous. Similarly, venlafaxine (an inhibitor of serotonin and norepinephrine reuptake) would have a positive effect.

It should be noted that there has been controversy about the IRS that, for all the cases observed in the studies, no cases of “completed” suicide were recorded among the children and adolescents included (self-mutilation and attempted suicide). In addition, the period of onset of suicidal behavior was mostly between the first few days and the first few weeks after initiation of treatment, and we recall that suicidal ideation and suicide attempts are frequent in the depressive episode clinic during teenagehood. Beyond these periods, the IRS would decrease suicide rates.

In the case of tricyclic antidepressants, the last meta-analyzes did not establish that the benefit / risk ratio was favorable. Although there is a trend in favor of clinical benefit in the adolescent group compared to that of children, the frequency and severity of adverse effects (mainly cardiovascular) is too high.

In the case of psychotic depression and bipolar disorder in adolescence, a mood stabilizer is used.

On the basis of the experience of each other, it appears that the use of lithium may be much earlier than was previously advised. However, the antithyroid effects of lithium require in-depth studies of the risks to growth, and its side effects mean that it is not intended as a first-line treatment. The prescription is the same as in adults (lithium level between 0.50 and 1 Meq / l with weekly and then monthly control). Anti-convulsant drugs (valproic acid, carbamazepine) are well known alternatives in adults in this type of disorder and can also be used in adolescence, especially in mixed bipolar disorder. As can occur in adults, it is necessary in many adolescents with psychotic manifestations but with bipolar disorder to use complementary antipsychotics.

Intervention on the environment:

Intervention on the environment can significantly alter the stalemate that takes place in a depressive climate experienced by the adolescent himself but also by his relatives. This intervention can be very varied in nature: change of lycée, section, development of a different place of life (internat for example), hospitalization so that conflicts can be expressed and “worked” without being repeated. However, this intervention must always aim at a process of separation-individuation or a work of mourning.

Hospitalization:

An adolescent is rarely hospitalized because he is only depressed. The familial or social context, the risks of self- or hetero-aggressive acts, and the foreseeable difficulties of adherence to therapy are decisive factors. It is preferable to hospitalize teenagers in places designed for them and in which teams used to receive these particular populations work.

In general, emergency hospitalization of adolescents is too often a catastrophe and is less responsive to the real gravity of a psychic situation than to the fact that the structures that hitherto housed them (familial or institutional) are suddenly overwhelmed by the anguish or violence they provoke. It is always best to prepare for hospitalization when possible.

In all cases it should be remembered that hospitalization is often only one of several stages in a nursing process that began before it and will continue after it.

The duration of hospitalizations varies but must be determined rather early. When the adolescent is hospitalized during a “crisis”, the hospitalization must be of short duration, in order to avoid social, educational and relational disintegration. In cases of severe depression, in which the social and family environment is a determining factor and a factor in the perpetuation of the disorders, it is necessary to know how to stay in hospital much longer or to be able to re-hospitalize frequently.

The role of hospital teams is to be available, tolerant but not complacent. It is in this context that it is possible to create a space containing and restore the limits that adolescents can not distinguish. The institution can be used as a mediation venue, helping to create a psychic space for teenagers too easily in the act and difficulty of mentalisation. It is necessary to be able to encourage narcissistic restoration through the framework, care, exchanges and encounters, while avoiding at the same time the excessive attitudes of mothering that favor the secondary benefits, and too great a requirement whereas not enough autonomy. A service welcoming teenagers must strive to be a place of intense relationship exchanges: exchanges with caregivers but also with peers. Depression in adolescence is particularly desocializing, so one must be very attentive to the schooling of adolescents. Care must be taken to encourage school re-entry as soon as it is medically possible, sometimes even before returning to the family.

The meetings with the parents must be regular and allow to retain or renew links. The discharge from hospitalization must also be prepared. Subsequent monitoring must be scheduled.

Prevention:

It seems essential even if the studies on this subject are insufficient. It is found both at the level of early childhood, as shown by the depression of abandonment, and at the level of adolescence. Recognition and treatment of depression in adolescence also allow preventive work to be carried out in the event of subsequent disorders in adulthood.

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Editor-in-chief of the Medical Actu website; general practitioner graduated from the Faculty of Medicine of Algiers in 2005 currently practicing as a liberal.

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