Classifying teenage depression

What is the right term to describe a 15-year-old who has been unhappy for as long as she can remember? Who is stuck in a family situation that seems unsolvable, with hostile separated parents who can’t talk to each other? Whose genuinely happy moments are contingent on fleeting circumstances, on a background of chronic but largely masked dysphoria? Who tries desperately to please but somehow can’t seem to make things work around her? Who regularly wonders if there is any point in going on and has been covertly cutting for a year or more?

To hear some people speak, or even my new trainee, fresh from his first year in adult psychiatry, you would think depression was a neatly defined entity, recognisable at 100 metres, for which a treatment algorithm will generate a positive outcome. My trainee, with repeated exposure under supervision, will gradually learn life is messier than that, and that ‘major depressive disorder’ is not a single entity at all, but a way of describing the experience of a number of people who travel different paths to arrive at similar but by no means identical destinations. He will learn to formulate and to individualise treatment, and to recognise what can and cannot be changed.

Why was no one able to help this girl? It would be nice to imagine that if we had seen her the outcome would have been different: we’re the experts after all. I’m not so sure. Treating depression in a ‘stuck’ predicament is uphill work. It’s hard to think if you can’t move and if you’ve been in the habit of keeping your pain to yourself you don’t drop your guard easily. I haven’t been impressed by the usefulness of medication in these situations and the evidence of efficacy for antidepressants in teenagers is hardly overwhelming (Cox et al., 2012). It can be slow, plodding work, and their suicidal thinking just sits there in a corner of the room with you, week after week, month after month.

Kuiper et al. (2014) highlight the fact that the better management of many cases of depression hangs on a fuller understanding of the psychosocial context and developmental history: something that should, of course, have formed part of the original assessment, or been explored systematically since. Isn’t that why we have the training and rigorous examination process – to get better at managing complexity? In the same issue, Mulder and Frampton (2014) comment on the persistence of depression despite all our advances in recent decades: ‘This review provides no support to the belief that pharmacological treatments have resulted in an improvement in the long-term outcome of patients with mood disorders’.

Unfortunately, neither the coroner nor the public have access to supervision, but we should try to educate them. Depression is not one illness, and suicide is as much about personality and predicament as it is about disorder. We do ourselves and the community a disservice when we pretend otherwise by over-simplifying and taking polarised positions.

See Viewpoint by Kuiper et al, 2014, 48(3): 219–223.

See Review by Mulder and Frampton, 2014, 48(3): 224–236.